Amd Ins L, generally; add §4406-j, amd §§4903, 4910 & 4914, Pub Health L; amd §§367-a & 364-j, Soc Serv L;
amd §§6810 & 6826-a, Ed L
Relates to access to appropriate drugs at reasonable prices, formulary exceptions, standing prior authorizations and external appeals; to access to retail pharmacies, prescription synchronization, limits on patient drug costs, explanations of benefits and rebates; to prescription drug synchronization; to pharmacy benefit management; and to limits on copayments and drug substitutions.
NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
BILL NUMBER: A8067
SPONSOR: Solages (MS) TITLE OF BILL:
An act to amend the insurance law and the public health law, in relation
to access to appropriate drugs at reasonable prices, formulary
exceptions, standing prior authorizations and external appeals; to amend
the insurance law, in relation to access to retail pharmacies,
prescription synchronization, limits on patient drug costs, explanations
of benefits and rebates; to amend the social services law, in relation
to prescription drug synchronization; and to amend the education law, in
relation to limits on copayments and drug substitutions
PURPOSE:
To establish a "Rx Common Sense" act aimed at establishing common sense
reforms to drug benefits. The reforms are designed to keep patients
informed of changes to their benefits and provide options to ensure
access to appropriate medications.
SUMMARY:
Section 1. Amends the insurance law by adding a new section 4807.
Section 2. Amends the public health law by adding a new section 4406-i.
Section 3. Amends section 4903 of the insurance law by adding a new
subsection (j).
Section 4. Amends section 4903 of the public health law by adding a new
subdivision 10.
Section 5. Amends subsection (b) of section 4910 of the insurance law by
adding a new paragraph 5.
Section 6. Amends subdivision 2 of section 4910 of the public health law
by adding a new paragraph (e).
Section 7. Amends paragraph 4 of subsection (b) of section 4914 of the
insurance law is amended by adding a new subparagraph (E).
Section 8. Amends paragraph (d) of subdivision 2 of section 4914 of the
public health law by adding a new subparagraph (E).
Section 9. Amends the opening paragraph of paragraph 28 of subsection
(i) of section 3216 of the insurance law is designated subparagraph
(A) and a new subparagraph (B).
Section 10. Amends the opening paragraph of paragraph 18 of subsection
(1) of section 3221 of the insurance law is designated subparagraph
(A) and a new subparagraph (B).
Section 11. Amends subsection (kk) of section 4303 of the insurance law
by adding a new paragraph 3.
Section 12. Amends the insurance law by adding a new section 3224-e.
Section 13. Amends the insurance law by adding a new section 4303-b.
Section 14. Amends subdivision 9 of section 367-a of the social services
law by adding a new paragraph (j).
Section 15. Amends subdivision 4 of section 364-j of the social services
law by adding a new paragraph (x).
Section 16. Amends subsection (h) of section 4325 of the insurance law,
as added by chapter 487 of the laws of 2010.
Section 17. Amends subdivision 6 of section 6810 of the education law by
adding a new paragraph (b-1).
Section 18. Amends section 6826-a of the education law by adding a new
subdivision 3.
Section 19. Amends paragraph 1 of subsection (e) of section 3231 of the
insurance law by adding a new subparagraph (C).
Section 20. Amends subsection (b) of section 3221 of the insurance law.
Section 21. Severability clause.
Section 22. Sets the effective date.
JUSTIFICATION:
This bill includes a wide range of common sense reforms designed to
ensure that prescription drug benefits in health insurance work for
patients. For example, the bill requires notice to patients before
changes such as formulary adjustments and additional utilization review
requirements. It would also provide protections, including transitional
coverage, when such changes negatively impact patients. Many of the
concepts have been included in legislation for a number of years, but as
aggressive management of pharmacy benefits has continued to grow, a
coordinated effort to address these related concerns is prudent.
The overarching theme of the reforms included in this bill is an effort
to respect patient choice and the prescriber-patient relationship. For
example, the bill would allow a prescriber to indicate that a retail
pharmacy is a more appropriate option for his or her patient under given
circumstances, and a health plan would be prohibited from imposing
mandatory mail order pharmacy. Another provision provides a mechanism
for a patient to seek coverage of a non-formulary drug when his or her
prescriber articulates it is therapeutically-appropriate and there is
not another appropriate option on the formulary. Such a determination
would be subject to external appeal.
RACIAL JUSTICE IMPACT:
TBD.
GENDER JUSTICE IMPACT:
TBD.
LEGISLATIVE HISTORY:
2021-22: A5046; referred to insurance.
2019-20: A4521; referred to insurance.
2017-18: A10215; referred to insurance.
FISCAL IMPLICATIONS:
None.
EFFECTIVE DATE:
This act shall take effect immediately and shall apply to insurance
policies issued, amended; or renewed on or after January 1, 2024;
provided, however, that the amendments to subdivision 9 of section 367-a
of the social services law made by section fourteen of this act shall
not affect the expiration of such subdivision pursuant to section 4 of
chapter 19 of the laws of 1998, as amended, and shall expire therewith;
and provided, further, that the amendments to section 364-j of the
social services law made by section fifteen of this act shall not affect
the repeal of such section and shall be deemed repealed therewith.
Effective immediately, the addition, amendment and/or repeal of any rule
or regulation necessary for the implementation of this act on its effec-
tive date are authorized to be made and completed on or before such
date.
STATE OF NEW YORK
________________________________________________________________________
8067
2023-2024 Regular Sessions
IN ASSEMBLY
September 27, 2023
___________
Introduced by M. of A. SOLAGES, TAYLOR, SEAWRIGHT, RAMOS, SIMON,
L. ROSENTHAL, GLICK, DICKENS, GUNTHER -- Multi-Sponsored by -- M. of
A. COOK -- read once and referred to the Committee on Insurance
AN ACT to amend the insurance law and the public health law, in relation
to access to appropriate drugs at reasonable prices, formulary
exceptions, standing prior authorizations and external appeals; to
amend the insurance law, in relation to access to retail pharmacies,
prescription synchronization, limits on patient drug costs, explana-
tions of benefits and rebates; to amend the social services law, in
relation to prescription drug synchronization; and to amend the educa-
tion law, in relation to limits on copayments and drug substitutions
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. The insurance law is amended by adding a new section 4807
2 to read as follows:
3 § 4807. Access to appropriate drugs at reasonable prices; formulary
4 exceptions; standing prior authorization requirement. (a) An insurer
5 offering a prescription drug benefit with a formulary of approved or
6 preferred drugs shall establish a procedure by which it determines
7 whether a formulary drug provides appropriate therapeutic benefits to
8 meet the particular health care needs of an insured. If the insurer
9 determines that no formulary drug provides appropriate therapeutic bene-
10 fits to meet the particular health care needs of an insured, the insurer
11 shall cover the cost of an off-formulary drug for that insured, at no
12 additional cost to the insured beyond what the insured would otherwise
13 pay for a preferred brand name drug on the formulary. The determinations
14 whether a drug provides appropriate therapeutic benefits and whether a
15 non-formulary drug is necessary to meet the particular health care needs
16 of the insured are utilization review decisions and are reviewable in
17 accordance with article forty-nine of this chapter, including external
18 appeal.
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD10957-02-3
A. 8067 2
1 (b) (1) For purposes of this section, "prior authorization require-
2 ment" means any practice implemented by an insurer in which coverage of
3 a prescription drug or device is dependent upon a covered person or a
4 health care practitioner obtaining approval from the insurer prior to
5 the service, device, or drug being performed, received, or prescribed,
6 as applicable. "Prior authorization" includes prospective or utilization
7 review procedures conducted prior to providing a drug or device.
8 (2) An insurer which requires prior authorizations for particular
9 prescription drugs shall have a procedure by which an insured who is
10 being prescribed such drug for a chronic condition may obtain a standing
11 prior authorization for a drug for the lesser of the following from the
12 date of the approval: (i) twelve months; or (ii) the last day of the
13 covered person's eligibility under the policy or plan.
14 (3) As a condition of such standing prior authorization, if according
15 to the available medical and scientific evidence the patient's chronic
16 condition is likely to change during the standing referral period, the
17 insurer or health plan may require the prescribing health care practi-
18 tioner to certify to the insurer, not more frequently than on a quarter-
19 ly basis, that the patient's chronic condition has not changed mate-
20 rially with respect to the need for the prescription.
21 (4) A twelve-month standing prior authorization provided under para-
22 graph two of this subsection does not apply to and is not required for
23 any of the following:
24 (i) medications that have a typical course of administration of less
25 than one year or for which available medical or scientific evidence does
26 not support a twelve-month period of use, in which case the standing
27 prior authorization period shall be the typical course of administration
28 or the period of use supported by the available medical or scientific
29 evidence;
30 (ii) medications that require an initial trial period to determine
31 effectiveness and tolerability, except that after such trial period a
32 one-year, or greater, prior authorization period will be given; and
33 (iii) medications that are schedule II controlled substance or a sche-
34 dule III controlled substance containing hydrocodone.
35 (5) For drugs used to treat acute conditions, insurers shall grant
36 standing prior authorizations for the period that the medical and scien-
37 tific evidence shows to be the anticipated period for the course of
38 treatment to have its intended effect.
39 (6) The standing prior authorizations provided for in this section are
40 no longer valid and automatically terminate if there are changes to
41 federal or state laws or federal regulatory guidance or compliance
42 information finding that the drug in question is no longer approved or
43 safe for the prescribed purpose.
44 (7) If an AB-rated generic drug that is therapeutically equivalent to
45 the drug subject to a standing prior authorization becomes available,
46 the insurer may substitute such newly released drug for the drug subject
47 to the standing prior authorization, provided advance notice is given to
48 the insured.
49 (8) The determination whether the drug is being prescribed to treat a
50 chronic condition and the period over which the course of treatment for
51 an acute condition is anticipated to have its intended effect are utili-
52 zation review decisions and are reviewable in accordance with article
53 forty-nine of this chapter, including external appeal.
54 (c) (1) If a formulary drug being prescribed for an insured is removed
55 by the insurer from its formulary for reasons other than a determination
56 that the approval for the use of that drug has been withdrawn by the
A. 8067 3
1 U.S. Food and Drug Administration, the insurer shall continue to cover
2 that drug for that insured for a transitional period to the end of the
3 plan year at the same copayment as charged when the drug was on formu-
4 lary. Thereafter, the insured may seek continued coverage of the drug,
5 if appropriate, pursuant to the provisions of subsection (a) of this
6 section.
7 (2) If a formulary drug being prescribed for an insured is moved by
8 the insurer to a higher cost sharing tier in its formulary for reasons
9 other than release of an AB-rated generic drug, the insurer shall
10 continue to cover that drug for that insured for a transitional period
11 to the end of the plan year at the same copayment as charged when the
12 drug was on formulary. Thereafter, the insured may seek continued cover-
13 age of the drug, if appropriate, pursuant to the provisions of
14 subsection (a) of this section.
15 (3) If an insurer that provides prescription drug coverage enrolls a
16 new insured who is currently being prescribed a drug for a chronic
17 health condition, or as part of an ongoing course of treatment for an
18 acute condition, and that drug is not on the insurer's formulary, the
19 insurer shall cover that drug for that insured at no additional cost to
20 the insured beyond what the insured would otherwise pay for a preferred
21 brand name drug on the formulary, for a transitional period of ninety
22 (90) days from the effective date of enrollment. The insured must adhere
23 to the insurer's quality assurance requirements and provide to the
24 insurer necessary medical information related to the prescription and
25 otherwise adhere to the insurer's policies and procedures including, but
26 not limited to procedures regarding obtaining pre-authorization and a
27 treatment plan approved by the insurer. In no event shall this
28 subsection be construed to require an insurer to provide coverage for
29 benefits not otherwise covered. The transitional period does not
30 preclude the insured from seeking continued coverage of the drug, if
31 appropriate, pursuant to the provisions of subsection (a) of this
32 section.
33 § 2. The public health law is amended by adding a new section 4406-j
34 to read as follows:
35 § 4406-j. Access to appropriate drugs at reasonable prices; formulary
36 exceptions; standing prior authorization requirement. 1. A health main-
37 tenance organization offering a prescription drug benefit with a formu-
38 lary of approved or preferred drugs shall have a procedure by which it
39 determines whether a formulary drug provides appropriate therapeutic
40 benefits to meet the particular health care needs of an enrollee. If the
41 health maintenance organization determines that no formulary drug
42 provides appropriate therapeutic benefits to meet the particular health
43 care needs of an enrollee, the health maintenance organization shall
44 cover the cost of an off-formulary drug for that enrollee, at no addi-
45 tional cost to the enrollee beyond what the enrollee would otherwise pay
46 for a preferred brand name drug on the formulary. The determinations
47 whether a drug provides appropriate therapeutic benefits and whether a
48 non-formulary drug is necessary to meet the particular health care needs
49 of the insured are utilization review decisions and are reviewable in
50 accordance with article forty-nine of this chapter, including external
51 appeal.
52 2. (a) For purposes of this section, "prior authorization requirement"
53 means any practice implemented by a health maintenance organization in
54 which coverage of a prescription drug or device is dependent upon a
55 covered person or a health care practitioner obtaining approval from the
56 health maintenance organization prior to the service, device, or drug
A. 8067 4
1 being performed, received, or prescribed, as applicable. "Prior authori-
2 zation" includes prospective or utilization review procedures conducted
3 prior to providing a drug or device.
4 (b) A health maintenance organization which requires prior authori-
5 zations for particular prescription drugs shall have a procedure by
6 which an enrollee who is being prescribed such drug for a chronic condi-
7 tion may obtain a standing prior authorization for a drug for the lesser
8 of the following from the date of the approval: (i) twelve months; (ii)
9 the last day of the enrollee's eligibility under the policy or plan.
10 (c) As a condition of such standing prior authorization, if according
11 to the available medical and scientific evidence the enrollee's chronic
12 condition is likely to change during the standing referral period, the
13 insurer or health plan may require the prescribing health care practi-
14 tioner to certify to the health maintenance organization, not more
15 frequently than on a quarterly basis, that the enrollee's chronic condi-
16 tion has not changed materially with respect to the need for the
17 prescription.
18 (d) A twelve-month standing prior authorization provided under subpar-
19 agraph (i) of paragraph (b) of this subdivision does not apply to and is
20 not required for any of the following:
21 (i) medications that have a typical course of administration of less
22 than one year or for which available medical or scientific evidence does
23 not support a twelve-month period of use, in which case the standing
24 prior authorization period shall be the typical course of administration
25 or the period of use supported by the available medical or scientific
26 evidence;
27 (ii) medications that require an initial trial period to determine
28 effectiveness and tolerability, except that after such trial period a
29 one-year, or greater, prior authorization period will be given; and
30 (iii) medications that are schedule II controlled substance or a sche-
31 dule III controlled substance containing hydrocodone.
32 (e) For drugs used to treat acute conditions, insurers shall grant
33 standing prior authorizations for the period that the medical and scien-
34 tific evidence shows to be the anticipated period for the course of
35 treatment to have its intended effect.
36 (f) The standing prior authorizations provided for in this section are
37 no longer valid and automatically terminate if there are changes to
38 federal or state laws or federal regulatory guidance or compliance
39 information finding that the drug in question is no longer approved or
40 safe for the prescribed purpose.
41 (g) If an AB-rated generic drug that is therapeutically equivalent to
42 the drug subject to a standing prior authorization becomes available,
43 the health maintenance organization may substitute such newly released
44 drug for the drug subject to the standing prior authorization, provided
45 advance notice is given to the enrollee.
46 (h) The determination whether the drug is being prescribed to treat a
47 chronic condition and the period over which the course of treatment for
48 an acute condition is anticipated to have its intended effect are utili-
49 zation review decisions and are reviewable in accordance with article
50 forty-nine of this chapter, including external appeal.
51 3. (a) If a formulary drug being prescribed for an enrollee is removed
52 by the health maintenance organization from its formulary for reasons
53 other than a determination that the approval for the use of that drug
54 has been withdrawn by the U.S. Food and Drug Administration, the health
55 maintenance organization shall continue to cover that drug for that
56 enrollee for a transitional period to the end of the plan year at the
A. 8067 5
1 same copayment as charged when the drug was on formulary. Thereafter,
2 the enrollee may seek continued coverage of the drug, if appropriate,
3 pursuant to the provisions of subdivision one of this section.
4 (b) If a formulary drug being prescribed for an insured is moved by
5 the health maintenance organization to a higher cost sharing tier in its
6 formulary for reasons other than release of an AB-rated generic drug,
7 the health maintenance organization shall continue to cover that drug
8 for that enrollee for a transitional period to the end of the plan year
9 at the same copayment as charged when the drug was on formulary. There-
10 after, the enrollee may seek continued coverage of the drug, if appro-
11 priate, pursuant to the provisions of subdivision one of this section.
12 (c) If a health maintenance organization that provides prescription
13 drug coverage enrolls a new enrollee who is currently being prescribed a
14 drug for a chronic health condition, or as part of an ongoing course of
15 treatment for an acute condition, and that drug is not on the health
16 maintenance organization's formulary, the health maintenance organiza-
17 tion shall cover that drug for that enrollee at no additional cost to
18 the enrollee beyond what the enrollee would otherwise pay for a
19 preferred brand name drug on the formulary, for a transitional period of
20 ninety (90) days from the effective date of enrollment. The enrollee
21 must adhere to the health maintenance organization's quality assurance
22 requirements and provide to the health maintenance organization neces-
23 sary medical information related to the prescription and otherwise
24 adhere to the health maintenance organization's policies and procedures
25 including, but not limited to procedures regarding obtaining pre-author-
26 ization and a treatment plan approved by the health maintenance organ-
27 ization. In no event shall this subdivision be construed to require a
28 health maintenance organization to provide coverage for benefits not
29 otherwise covered. The transitional period does not preclude the enrol-
30 lee from seeking continued coverage of the drug, if appropriate, pursu-
31 ant to the provisions of subdivision one of this section.
32 § 3. Section 4903 of the insurance law is amended by adding a new
33 subsection (j) to read as follows:
34 (j) (1) Each health plan shall make available to all participating
35 health care providers on its web site or provider portal a listing of
36 its prior authorization requirements, including specific information or
37 documentation that a provider must submit in order for the prior author-
38 ization request to be considered complete.
39 (2) Each health plan shall make available on its web site information
40 about the policies, contracts, or agreements offered by it that clearly
41 identifies specific services, drugs, or devices to which a prior author-
42 ization requirement exists.
43 (3) Each health plan shall give thirty (30) days advance written
44 notice to participating providers of any changes in prior authorization
45 requirements. Each health plan shall also give thirty (30) days advance
46 written notice to plan participants of any changes in prior authori-
47 zation requirements with respect to any services, drugs or devices which
48 such participant is currently being prescribed or has been prescribed in
49 the preceding year.
50 § 4. Section 4903 of the public health law is amended by adding a new
51 subdivision 10 to read as follows:
52 10. (a) Each health plan shall make available to all participating
53 health care providers on its web site or provider portal a listing of
54 its prior authorization requirements, including specific information or
55 documentation that a provider must submit in order for the prior author-
56 ization request to be considered complete.
A. 8067 6
1 (b) Each health plan shall make available on its web site information
2 about the policies, contracts, or agreements offered by it that clearly
3 identifies specific services, drugs, or devices to which a prior author-
4 ization requirement exists.
5 (c) Each health plan shall give thirty (30) days advance written
6 notice to participating providers of any changes in prior authorization
7 requirements. Each health plan shall also give thirty (30) days advance
8 written notice to plan participants of any changes in prior authori-
9 zation requirements with respect to any services, drugs or devices which
10 such participant is currently being prescribed or has been prescribed in
11 the preceding year.
12 § 5. Subsection (b) of section 4910 of the insurance law is amended by
13 adding a new paragraph 5 to read as follows:
14 (5) (A) The insured has had a drug prescription denied on the ground
15 that it is not on the health care plan's formulary, and that the health
16 care plan has a covered drug on the formulary which is effective to meet
17 the particular health care needs of an insured; and
18 (B) The insured's attending physician, who shall be a licensed physi-
19 cian or other health care provider qualified to prescribe drugs to treat
20 the insured for the health service sought, certifies that available
21 formulary drugs are not sufficiently effective to meet the insured's
22 health needs, or are otherwise contraindicated for the insured, and
23 recommends an off-formulary drug that will be effective to treat the
24 insured.
25 § 6. Subdivision 2 of section 4910 of the public health law is amended
26 by adding a new paragraph (e) to read as follows:
27 (e) (i) The enrollee has had a drug prescription denied on the ground
28 that it is not on the health maintenance organization's formulary, and
29 that the health maintenance organization has a covered drug on the
30 formulary which is effective to meet the particular health care needs of
31 an enrollee; and
32 (ii) The enrollee's attending physician, who shall be a licensed
33 physician or other health care provider qualified to prescribe drugs to
34 treat the insured for the health service sought, certifies that avail-
35 able formulary drugs are not sufficiently effective to meet the
36 enrollee's health needs, or are otherwise contraindicated for the enrol-
37 lee, and recommends an off-formulary drug that will be effective to
38 treat the enrollee.
39 § 7. Paragraph 4 of subsection (b) of section 4914 of the insurance
40 law is amended by adding a new subparagraph (E) to read as follows:
41 (E) For external appeals requested pursuant to paragraph five of
42 subsection (b) of section four thousand nine hundred ten of this title
43 relating to an off-formulary drug denial, the external appeal agent
44 shall review the utilization review agent's final adverse determination
45 and, in accordance with the provisions of this title, shall make a
46 determination as to whether the non-formulary drug shall be covered by
47 the health plan; provided that such determination shall:
48 (i) be conducted only by one or a greater odd number of clinical peer
49 reviewers;
50 (ii) be accompanied by a written statement:
51 (I) that the off-formulary drug prescription shall be covered by the
52 health care plan either when the reviewer or a majority of the panel of
53 reviewers determines, upon review of the available medical and scientif-
54 ic evidence, the formulary drug deemed sufficient by the health plan
55 will not be as effective in addressing the insured's health problem for
56 which a drug has been prescribed as the off-formulary drug prescribed by
A. 8067 7
1 the treating physician or otherwise be appropriate to meet the partic-
2 ular health care needs of the insured, which is more likely to provide a
3 beneficial clinical outcome; or
4 (II) upholding the health plan's denial of coverage.
5 § 8. Paragraph (d) of subdivision 2 of section 4914 of the public
6 health law is amended by adding a new subparagraph (E) to read as
7 follows:
8 (E) For external appeals requested pursuant to paragraph (e) of subdi-
9 vision two of section forty-nine hundred ten of this title relating to
10 an off-formulary drug denial, the external appeal agent shall review the
11 utilization review agent's final adverse determination and, in accord-
12 ance with the provisions of this title, shall make a determination as to
13 whether the non-formulary drug shall be covered by the health mainte-
14 nance organization; provided that such determination shall:
15 (i) be conducted only by one or a greater odd number of clinical peer
16 reviewers;
17 (ii) be accompanied by a written statement:
18 (1) that the off-formulary drug prescription shall be covered by the
19 health maintenance organization either when the reviewer or a majority
20 of the panel of reviewers determines, upon review of the available
21 medical and scientific evidence, the formulary drug deemed sufficient by
22 the health maintenance organization will not be as effective in address-
23 ing the enrollee's health problem for which a drug has been prescribed
24 as the off-formulary drug prescribed by the treating physician or other-
25 wise be appropriate to meet the particular health care needs of the
26 enrollee, which is more likely to provide a beneficial clinical outcome;
27 or
28 (2) upholding the health maintenance organization's denial of cover-
29 age.
30 § 9. The opening paragraph of paragraph 28 of subsection (i) of
31 section 3216 of the insurance law is designated subparagraph (A) and a
32 new subparagraph (B) is added to read as follows:
33 (B) Notwithstanding any other provision of this paragraph, if a pres-
34 criber, after consulting with the insurer regarding the appropriateness
35 of mail order delivery given: (i) the residence or delivery location of
36 the insured; (ii) the medical condition of the insured; (iii) the stor-
37 age requirements of the drug; (iv) the availability of the insured to
38 receive the prescription; or (v) the insured's ability to comprehend
39 pharmaceutical guidance and support over the telephone, determines that
40 a drug as prescribed on an individual basis is most appropriately filled
41 at a retail location, provided that an in-network retail pharmacy of the
42 patient's choosing agrees to the same reimbursement amount and is able
43 to fill the prescription, the prescriber's determination shall be final.
44 § 10. The opening paragraph of paragraph 18 of subsection (1) of
45 section 3221 of the insurance law is designated subparagraph (A) and a
46 new subparagraph (B) is added to read as follows:
47 (B) Notwithstanding any other provision of this paragraph, if a pres-
48 criber, after consulting with the insurer regarding the appropriateness
49 of mail order delivery given: (i) the residence or delivery location of
50 the insured; (ii) the medical condition of the insured; (iii) the stor-
51 age requirements of the drug; (iv) the availability of the insured to
52 receive the prescription; or (v) the insured's ability to comprehend
53 pharmaceutical guidance and support over the telephone, determines that
54 a drug as prescribed on an individual basis is most appropriately filled
55 at a retail location, provided that an in-network retail pharmacy of the
A. 8067 8
1 patient's choosing agrees to the same reimbursement amount and is able
2 to fill the prescription, the prescriber's determination shall be final.
3 § 11. Subsection (kk) of section 4303 of the insurance law is amended
4 by adding a new paragraph 3 to read as follows:
5 (3) Notwithstanding any other provision of this subsection, if a pres-
6 criber, after consulting with the insurer regarding the appropriateness
7 of mail order delivery given: (A) the residence or delivery location of
8 the covered person; (B) the medical condition of the covered person; (C)
9 the storage requirements of the drug; (D) the availability of the
10 covered person to receive the prescription; or (E) the covered person's
11 ability to comprehend pharmaceutical guidance and support over the tele-
12 phone, determines that a drug as prescribed on an individual basis is
13 most appropriately filled at a retail location, provided that an in-net-
14 work retail pharmacy of the patient's choosing agrees to the same
15 reimbursement amount and is able to fill the prescription, the
16 prescriber's determination shall be final.
17 § 12. The insurance law is amended by adding a new section 3224-e to
18 read as follows:
19 § 3224-e. Prescription synchronization. (a) Every individual or group
20 health insurance policy providing prescription drug coverage when appli-
21 cable to permit synchronization shall permit and apply a daily prorated
22 cost-sharing rate to prescriptions that are dispensed by a network phar-
23 macy for less than a thirty day supply, when it is agreed among the
24 covered individual, a health care practitioner, and a pharmacist that
25 synchronization of multiple prescriptions for the treatment of a chronic
26 illness is in the best interest of the covered individual for the
27 management or treatment of that chronic illness provided that all of the
28 following apply:
29 (1) the medications are covered by the policy or plan;
30 (2) the medications are used for treatment and management of chronic
31 conditions that are subject to refills;
32 (3) the medications are not a schedule II controlled substance or a
33 schedule III controlled substance containing hydrocodone;
34 (4) the medications meet all prior authorization criteria specific to
35 medications at the time of the synchronization request;
36 (5) the medications are of a formulation that can be effectively split
37 over required short fill periods to achieve synchronization; and
38 (6) the medications do not have quantity limits or dose optimization
39 criteria or requirements that would be violated in fulfilling synchroni-
40 zation.
41 (b) No individual or group health insurance policy providing
42 prescription drug coverage shall deny coverage for the dispensing of a
43 medication for partial fill when it is for purposes of synchronizing the
44 patient's medications. When applicable to permit synchronization, every
45 individual or group health insurance policy must allow a pharmacy to
46 override any denial codes indicating that a prescription is being
47 refilled too soon for the purposes of medication synchronization.
48 (c) Dispensing fees for partially filled or refilled prescriptions
49 shall be paid in full for each prescription dispensed, regardless of any
50 pro-rated copay for the beneficiary or fee paid for alignment services.
51 (d) Nothing in this section shall be deemed to require health care
52 practitioners and pharmacists to synchronize the refilling of multiple
53 prescriptions for a covered individual.
54 (e) The requirements of this section shall apply only once for each
55 prescription drug subject to medication synchronization except when
56 either of the following occurs:
A. 8067 9
1 (1) the prescriber changes the dosage or frequency of administration
2 of the prescription drug subject to a medication synchronization; or
3 (2) the prescriber prescribes a different drug.
4 § 13. The insurance law is amended by adding a new section 4303-b to
5 read as follows:
6 § 4303-b. Prescription synchronization. (a) Every hospital service
7 corporation and health service corporation providing prescription drug
8 coverage when applicable to permit synchronization shall permit and
9 apply a daily prorated cost-sharing rate to prescriptions that are
10 dispensed by a network pharmacy for less than a thirty day supply, when
11 it is agreed among the covered individual, a health care practitioner,
12 and a pharmacist that synchronization of multiple prescriptions for the
13 treatment of a chronic illness is in the best interest of the covered
14 individual for the management or treatment of that chronic illness
15 provided that all of the following apply:
16 (1) the medications are covered by the policy or plan;
17 (2) the medications are used for treatment and management of chronic
18 conditions that are subject to refills;
19 (3) the medications are not a schedule II controlled substance or a
20 schedule III controlled substance containing hydrocodone;
21 (4) the medications meet all prior authorization criteria specific to
22 medications at the time of the synchronization request;
23 (5) the medications are of a formulation that can be effectively split
24 over required short fill periods to achieve synchronization; and
25 (6) the medications do not have quantity limits or dose optimization
26 criteria or requirements that would be violated in fulfilling synchroni-
27 zation.
28 (b) No hospital service corporation or health service corporation
29 providing prescription drug coverage shall deny coverage for the
30 dispensing of a medication for partial fill when it is for purposes of
31 synchronizing the patient's medications. When applicable to permit
32 synchronization, every hospital service corporation or health service
33 corporation providing prescription drug coverage must allow a pharmacy
34 to override any denial codes indicating that a prescription is being
35 refilled too soon for the purposes of medication synchronization.
36 (c) Dispensing fees for partially filled or refilled prescriptions
37 shall be paid in full for each prescription dispensed, regardless of any
38 pro-rated copay for the beneficiary or fee paid for alignment services.
39 (d) Nothing in this section shall be deemed to require health care
40 practitioners and pharmacists to synchronize the refilling of multiple
41 prescriptions for a covered individual.
42 (e) The requirements of this section shall apply only once for each
43 prescription drug subject to medication synchronization except when
44 either of the following occurs:
45 (1) The prescriber changes the dosage or frequency of administration
46 of the prescription drug subject to a medication synchronization; or
47 (2) The prescriber prescribes a different drug.
48 § 14. Subdivision 9 of section 367-a of the social services law is
49 amended by adding a new paragraph (j) to read as follows:
50 (j) (i) The department of health shall establish a program for
51 synchronization of medications when it is agreed among the recipient, a
52 provider and a pharmacist that synchronization of multiple prescriptions
53 for the treatment of a chronic illness is in the best interest of the
54 patient for the management or treatment of a chronic illness provided
55 that the medications:
56 (A) are covered by the department of health pursuant to this title;
A. 8067 10
1 (B) are used for treatment and management of chronic conditions that
2 are subject to refills;
3 (C) are not a schedule II controlled substance or a schedule III
4 controlled substance containing hydrocodone;
5 (D) meet all prior authorization criteria specific to the medications
6 at the time of the synchronization request;
7 (E) are of a formulation that can be effectively split over required
8 short fill periods to achieve synchronization; and
9 (F) do not have quantity limits or dose optimization criteria or
10 requirements that would be violated in fulfilling synchronization.
11 (ii) The department of health shall not deny coverage for the dispens-
12 ing of a medication by a network pharmacy for a partial supply when it
13 is for the purpose of synchronizing the patient's medications. When
14 applicable to permit synchronization, the department of health shall
15 allow a pharmacy to override any denial codes indicating that a
16 prescription is being refilled too soon for the purposes of medication
17 synchronization.
18 (iii) To permit synchronization, the department of health shall apply
19 a prorated daily cost-sharing rate to any medication dispensed by a
20 network pharmacy pursuant to this section.
21 (iv) The dispensing fee paid to a network pharmacy contracted to
22 provide services pursuant to this section for a partial supply associ-
23 ated with a medication synchronization shall be paid in full and shall
24 not be prorated.
25 (v) The requirements of this paragraph applies only once for each
26 prescription drug subject to medication synchronization except when
27 either of the following occurs:
28 (A) the prescriber changes the dosage or frequency of administration
29 of the prescription drug subject to a medication synchronization; or
30 (B) the prescriber prescribes a different drug.
31 (vi) Nothing in this paragraph shall be deemed to require health care
32 practitioners and pharmacists to synchronize the refilling of multiple
33 prescriptions for a recipient.
34 § 15. Subdivision 4 of section 364-j of the social services law is
35 amended by adding a new paragraph (x) to read as follows:
36 (x) (i) The department of health or a managed care organization
37 contracted to provide services pursuant to this section shall establish
38 a program for synchronization of medications when it is agreed among the
39 recipient, a provider and a pharmacist that synchronization of multiple
40 prescriptions for the treatment of a chronic illness is in the best
41 interest of the patient for the management or treatment of a chronic
42 illness provided that the medications:
43 (A) are covered by Medicaid services or a managed care organization
44 contracted to provide services pursuant to this chapter;
45 (B) are used for treatment and management of chronic conditions that
46 are subject to refills;
47 (C) are not a schedule II controlled substance or a schedule III
48 controlled substance containing hydrocodone;
49 (D) meet all prior authorization criteria specific to the medications
50 at the time of the synchronization request;
51 (E) are of a formulation that can be effectively split over required
52 short fill periods to achieve synchronization; and
53 (F) do not have quantity limits or dose optimization criteria or
54 requirements that would be violated in fulfilling synchronization.
55 (ii) The department of health or a managed care organization
56 contracted to provide services under this section shall not deny cover-
A. 8067 11
1 age for the dispensing of a medication by a network pharmacy for a
2 partial supply when it is for the purpose of synchronizing the patient's
3 medications. When applicable to permit synchronization, the department
4 of health or a managed care organization contracted to provide services
5 under this title shall allow a pharmacy to override any denial code
6 indicating that a prescription is being refilled too soon for the
7 purposes of medication synchronization.
8 (iii) To permit synchronization, the department of health or a managed
9 care organization contracted to provide services pursuant to this title
10 shall apply a prorated daily cost-sharing rate to any medication
11 dispensed by a network pharmacy pursuant to this section.
12 (iv) The dispensing fee paid to a network pharmacy contracted to
13 provide services pursuant to this section for a partial supply associ-
14 ated with a medication synchronization shall be paid in full and shall
15 not be prorated.
16 (v) The requirements of this paragraph applies only once for each
17 prescription drug subject to medication synchronization except when
18 either of the following occurs:
19 (A) the prescriber changes the dosage or frequency of administration
20 of the prescription drug subject to a medication synchronization; or
21 (B) the prescriber prescribes a different drug.
22 (vi) Nothing in this paragraph shall be deemed to require health care
23 practitioners and pharmacists to synchronize the refilling of multiple
24 prescriptions for a covered individual.
25 § 16. Subsection (h) of section 4325 of the insurance law, as added by
26 chapter 487 of the laws of 2010, is amended to read as follows:
27 (h) (i) No corporation or insurer organized or licensed under this
28 chapter which provides coverage for prescription drugs shall require, or
29 enter into a contract which permits, a copayment which exceeds the usual
30 and customary cost of such prescribed drug or which exceeds the total
31 price paid to the pharmacy for such prescribed drug after the insured
32 has met the annual deductible requirement.
33 (ii) In determining any coinsurance amount required to be paid for a
34 prescription drug, no insurer or corporation organized under this chap-
35 ter shall base its computation on a price higher than the actual price
36 paid by the pharmacy for the drug, taking into account any rebates
37 specific to the drug. The department of financial services shall issue
38 regulations setting forth the method each insurer or corporation organ-
39 ized under this chapter must use to determine the actual price paid by
40 the pharmacy.
41 (iii) Each insurer or corporation licensed under this article which
42 offers prescription drug coverage must itself or through its pharmacy
43 benefit manager issue a written explanation of benefit form to its
44 enrollees with respect to each prescription filled, containing all cate-
45 gories of information required of explanation of benefits forms for
46 medical benefits.
47 § 17. Subdivision 6 of section 6810 of the education law is amended by
48 adding a new paragraph (b-1) to read as follows:
49 (b-1) The prescriber or pharmacist shall inform the patient whether he
50 or she has prescribed or substituted a different generic drug product
51 from the generic drug product the patient has previously received.
52 Notification required pursuant to this paragraph shall be provided both
53 written and orally, contemporaneously with the filling of the
54 prescription.
55 § 18. Section 6826-a of the education law is amended by adding a new
56 subdivision 3 to read as follows:
A. 8067 12
1 3. The copayment amount shall not exceed the total price paid to the
2 pharmacy for the prescribed drug, except in cases where the insured has
3 not met the annual deductible requirement. The copayment charged to a
4 consumer for a prescription drug shall not exceed the amount which would
5 be charged if the drug were purchased without insurance coverage.
6 § 19. Paragraph 1 of subsection (e) of section 3231 of the insurance
7 law is amended by adding a new subparagraph (C) to read as follows:
8 (C) an insurer shall annually certify to the department that, during
9 the prior benefit year, the insurer made available to enrollees at the
10 point of sale at least a majority (i.e., greater than fifty percent) of
11 the rebates.
12 (i) For purposes of this subparagraph, "rebate" means:
13 (1) negotiated price concessions including but not limited to base
14 rebates and reasonable estimates of any price protection rebates and
15 performance-based rebates that may accrue directly or indirectly to the
16 issuer during the coverage year from a manufacturer, dispensing pharma-
17 cy, or other party to the transaction; and
18 (2) reasonable estimates of any fees and other administrative costs
19 that are passed through to the issuer and serve to reduce the issuer's
20 prescription drug liabilities for the coverage year.
21 (ii) In providing the certification required under this section, an
22 issuer shall not publish or otherwise reveal information regarding the
23 actual amount of rebates the issuer received on a product-, manufactur-
24 er-, or pharmacy-specific basis. Such information is protected as a
25 trade secret, is not a public record as defined in the public officers
26 law and shall not be disclosed directly or indirectly. An insurer shall
27 impose the confidentiality protections of this section on any third
28 parties or vendors with which it contracts that may receive or have
29 access to rebate information.
30 § 20. Subsection (b) of section 3221 of the insurance law is amended
31 to read as follows:
32 (b) (1) No such policy shall be delivered or issued for delivery in
33 this state unless a schedule of the premium rates pertaining to such
34 form shall have been filed with the superintendent.
35 (2) An insurer shall annually certify to the department that, during
36 the prior benefit year, the insurer made available to enrollees at the
37 point of sale at least a majority (i.e., greater than fifty percent) of
38 the rebates.
39 (A) For purposes of this paragraph, "rebate" means:
40 (i) Negotiated price concessions including but not limited to base
41 rebates and reasonable estimates of any price protection rebates and
42 performance-based rebates that may accrue directly or indirectly to the
43 issuer during the coverage year from a manufacturer, dispensing pharma-
44 cy, or other party to the transaction; and
45 (ii) Reasonable estimates of any fees and other administrative costs
46 that are passed through to the issuer and serve to reduce the issuer's
47 prescription drug liabilities for the coverage year.
48 (B) In providing the certification required under this section, an
49 issuer shall not publish or otherwise reveal information regarding the
50 actual amount of rebates the issuer received on a product-, manufactur-
51 er-, or pharmacy-specific basis. Such information is protected as a
52 trade secret, is not a public record as defined in the public officers
53 law and shall not be disclosed directly or indirectly. An insurer shall
54 impose the confidentiality protections of this section on any third
55 parties or vendors with which it contracts that may receive or have
56 access to rebate information.
A. 8067 13
1 § 21. Severability. If any item, clause, sentence, subparagraph,
2 subdivision or other part of this act, or the application thereof to any
3 person or circumstances shall be held to be invalid, such holding shall
4 not affect, impair or invalidate the remainder of this act but it shall
5 be confined in its operation to the item, clause, sentence, subpara-
6 graph, subdivision or other part of this act directly involved in such
7 holding, or to the person and circumstances therein involved.
8 § 22. This act shall take effect immediately and shall apply to insur-
9 ance policies issued, amended, or renewed on or after January 1, 2024;
10 provided, however, that the amendments to subdivision 9 of section 367-a
11 of the social services law made by section fourteen of this act shall
12 not affect the expiration of such subdivision pursuant to section 4 of
13 chapter 19 of the laws of 1998, as amended, and shall expire therewith;
14 and provided, further, that the amendments to section 364-j of the
15 social services law made by section fifteen of this act shall not affect
16 the repeal of such section and shall be deemed repealed therewith.
17 Effective immediately, the addition, amendment and/or repeal of any rule
18 or regulation necessary for the implementation of this act on its effec-
19 tive date are authorized to be made and completed on or before such
20 date.
