A10215 Summary:

BILL NOA10215
 
SAME ASSAME AS S08651
 
SPONSORSolages
 
COSPNSRTaylor, Dickens, Rosenthal L, D'Urso, Ramos, Simon, Gunther, Arroyo, Jaffee, Glick, Gottfried, Barron, Blake, Lawrence, Errigo, Montesano, Seawright, Wright
 
MLTSPNSRCook
 
Add §§4806, 3224-d & 4303-a, amd §§4903, 4910, 4914, 3216, 3221, 4303, 4325 & 3231, Ins L; add §4406-h, amd §§4903, 4910, 4914 & 280-a, 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.
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A10215 Actions:

BILL NOA10215
 
03/26/2018referred to insurance
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A10215 Committee Votes:

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A10215 Floor Votes:

There are no votes for this bill in this legislative session.
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A10215 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                          10215
 
                   IN ASSEMBLY
 
                                     March 26, 2018
                                       ___________
 
        Introduced  by M. of A. SOLAGES -- read once and referred to the Commit-
          tee 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; to amend the public
          health law, in relation to pharmacy benefit management; and  to  amend
          the  education  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 4806
     2  to read as follows:
     3    § 4806. 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.
    19    (b)  (1)  For  purposes of this section, "prior authorization require-
    20  ment" means any practice implemented by an insurer in which coverage  of
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD15227-01-8

        A. 10215                            2
 
     1  a  prescription  drug  or device is dependent upon a covered person or a
     2  health care practitioner obtaining approval from the  insurer  prior  to
     3  the  service,  device, or drug being performed, received, or prescribed,
     4  as applicable. "Prior authorization" includes prospective or utilization
     5  review procedures conducted prior to providing a drug or device.
     6    (2)  An  insurer  which  requires  prior authorizations for particular
     7  prescription drugs shall have a procedure by which  an  insured  who  is
     8  being prescribed such drug for a chronic condition may obtain a standing
     9  prior  authorization for a drug for the lesser of the following from the
    10  date of the approval: (i) twelve months; or (ii) the  last  day  of  the
    11  covered person's eligibility under the policy or plan.
    12    (3)  As a condition of such standing prior authorization, if according
    13  to the available medical and scientific evidence the  patient's  chronic
    14  condition  is  likely to change during the standing referral period, the
    15  insurer or health plan may require the prescribing health  care  practi-
    16  tioner to certify to the insurer, not more frequently than on a quarter-
    17  ly  basis,  that  the  patient's chronic condition has not changed mate-
    18  rially with respect to the need for the prescription.
    19    (4) A twelve-month standing prior authorization provided  under  para-
    20  graph  two  of this subsection does not apply to and is not required for
    21  any of the following:
    22    (i) medications that have a typical course of administration  of  less
    23  than one year or for which available medical or scientific evidence does
    24  not  support  a  twelve-month  period of use, in which case the standing
    25  prior authorization period shall be the typical course of administration
    26  or the period of use supported by the available  medical  or  scientific
    27  evidence;
    28    (ii)  medications  that  require  an initial trial period to determine
    29  effectiveness and tolerability, except that after such  trial  period  a
    30  one-year, or greater, prior authorization period will be given; and
    31    (iii) medications that are schedule II controlled substance or a sche-
    32  dule III controlled substance containing hydrocodone.
    33    (5)  For  drugs  used  to treat acute conditions, insurers shall grant
    34  standing prior authorizations for the period that the medical and scien-
    35  tific evidence shows to be the anticipated  period  for  the  course  of
    36  treatment to have its intended effect.
    37    (6) The standing prior authorizations provided for in this section are
    38  no  longer  valid  and  automatically  terminate if there are changes to
    39  federal or state laws  or  federal  regulatory  guidance  or  compliance
    40  information  finding  that the drug in question is no longer approved or
    41  safe for the prescribed purpose.
    42    (7) If an AB-rated generic drug that is therapeutically equivalent  to
    43  the  drug  subject  to a standing prior authorization becomes available,
    44  the insurer may substitute such newly released drug for the drug subject
    45  to the standing prior authorization, provided advance notice is given to
    46  the insured.
    47    (8) The determination whether the drug is being prescribed to treat  a
    48  chronic  condition and the period over which the course of treatment for
    49  an acute condition is anticipated to have its intended effect are utili-
    50  zation review decisions and are reviewable in  accordance  with  article
    51  forty-nine of this chapter, including external appeal.
    52    (c) (1) If a formulary drug being prescribed for an insured is removed
    53  by the insurer from its formulary for reasons other than a determination
    54  that  the  approval  for  the use of that drug has been withdrawn by the
    55  U.S. Food and Drug Administration, the insurer shall continue  to  cover
    56  that  drug  for that insured for a transitional period to the end of the

        A. 10215                            3
 
     1  plan year at the same copayment as charged when the drug was  on  formu-
     2  lary.   Thereafter, the insured may seek continued coverage of the drug,
     3  if appropriate, pursuant to the provisions of  subsection  (a)  of  this
     4  section.
     5    (2)  If  a  formulary drug being prescribed for an insured is moved by
     6  the insurer to a higher cost sharing tier in its formulary  for  reasons
     7  other  than  release  of  an  AB-rated  generic  drug, the insurer shall
     8  continue to cover that drug for that insured for a  transitional  period
     9  to  the  end  of the plan year at the same copayment as charged when the
    10  drug was on formulary. Thereafter, the insured may seek continued cover-
    11  age  of  the  drug,  if  appropriate,  pursuant  to  the  provisions  of
    12  subsection (a) of this section.
    13    (3)  If  an insurer that provides prescription drug coverage enrolls a
    14  new insured who is currently being  prescribed  a  drug  for  a  chronic
    15  health  condition,  or  as part of an ongoing course of treatment for an
    16  acute condition, and that drug is not on the  insurer's  formulary,  the
    17  insurer  shall cover that drug for that insured at no additional cost to
    18  the insured beyond what the insured would otherwise pay for a  preferred
    19  brand  name  drug  on the formulary, for a transitional period of ninety
    20  (90) days from the effective date of enrollment. The insured must adhere
    21  to the insurer's quality  assurance  requirements  and  provide  to  the
    22  insurer  necessary  medical  information related to the prescription and
    23  otherwise adhere to the insurer's policies and procedures including, but
    24  not limited to procedures regarding obtaining  pre-authorization  and  a
    25  treatment  plan  approved  by  the  insurer.  In  no  event  shall  this
    26  subsection be construed to require an insurer to  provide  coverage  for
    27  benefits  not  otherwise  covered.  The  transitional  period  does  not
    28  preclude the insured from seeking continued coverage  of  the  drug,  if
    29  appropriate,  pursuant  to  the  provisions  of  subsection  (a) of this
    30  section.
    31    § 2. The public health law is amended by adding a new  section  4406-h
    32  to read as follows:
    33    §  4406-h. Access to appropriate drugs at reasonable prices; formulary
    34  exceptions; standing prior authorization requirement. 1. A health  main-
    35  tenance  organization offering a prescription drug benefit with a formu-
    36  lary of approved or preferred drugs shall have a procedure by  which  it
    37  determines  whether  a  formulary  drug provides appropriate therapeutic
    38  benefits to meet the particular health care needs of an enrollee. If the
    39  health  maintenance  organization  determines  that  no  formulary  drug
    40  provides  appropriate therapeutic benefits to meet the particular health
    41  care needs of an enrollee, the  health  maintenance  organization  shall
    42  cover  the  cost of an off-formulary drug for that enrollee, at no addi-
    43  tional cost to the enrollee beyond what the enrollee would otherwise pay
    44  for a preferred brand name drug on  the  formulary.  The  determinations
    45  whether  a  drug provides appropriate therapeutic benefits and whether a
    46  non-formulary drug is necessary to meet the particular health care needs
    47  of the insured are utilization review decisions and  are  reviewable  in
    48  accordance  with  article forty-nine of this chapter, including external
    49  appeal.
    50    2. (a) For purposes of this section, "prior authorization requirement"
    51  means any practice implemented by a health maintenance  organization  in
    52  which  coverage  of  a  prescription  drug or device is dependent upon a
    53  covered person or a health care practitioner obtaining approval from the
    54  health maintenance organization prior to the service,  device,  or  drug
    55  being performed, received, or prescribed, as applicable. "Prior authori-

        A. 10215                            4
 
     1  zation"  includes prospective or utilization review procedures conducted
     2  prior to providing a drug or device.
     3    (b)  A  health  maintenance organization which requires prior authori-
     4  zations for particular prescription drugs  shall  have  a  procedure  by
     5  which an enrollee who is being prescribed such drug for a chronic condi-
     6  tion may obtain a standing prior authorization for a drug for the lesser
     7  of the following from the date of the approval:  (i) twelve months; (ii)
     8  the last day of the enrollee's eligibility under the policy or plan.
     9    (c)  As a condition of such standing prior authorization, if according
    10  to the available medical and scientific evidence the enrollee's  chronic
    11  condition  is  likely to change during the standing referral period, the
    12  insurer or health plan may require the prescribing health  care  practi-
    13  tioner  to  certify  to  the  health  maintenance organization, not more
    14  frequently than on a quarterly basis, that the enrollee's chronic condi-
    15  tion has not changed  materially  with  respect  to  the  need  for  the
    16  prescription.
    17    (d) A twelve-month standing prior authorization provided under subpar-
    18  agraph (i) of paragraph (b) of this subdivision does not apply to and is
    19  not required for any of the following:
    20    (i)  medications  that have a typical course of administration of less
    21  than one year or for which available medical or scientific evidence does
    22  not support a twelve-month period of use, in  which  case  the  standing
    23  prior authorization period shall be the typical course of administration
    24  or  the  period  of use supported by the available medical or scientific
    25  evidence;
    26    (ii) medications that require an initial  trial  period  to  determine
    27  effectiveness  and  tolerability,  except that after such trial period a
    28  one-year, or greater, prior authorization period will be given; and
    29    (iii) medications that are schedule II controlled substance or a sche-
    30  dule III controlled substance containing hydrocodone.
    31    (e) For drugs used to treat acute  conditions,  insurers  shall  grant
    32  standing prior authorizations for the period that the medical and scien-
    33  tific  evidence  shows  to  be  the anticipated period for the course of
    34  treatment to have its intended effect.
    35    (f) The standing prior authorizations provided for in this section are
    36  no longer valid and automatically terminate  if  there  are  changes  to
    37  federal  or  state  laws  or  federal  regulatory guidance or compliance
    38  information finding that the drug in question is no longer  approved  or
    39  safe for the prescribed purpose.
    40    (g)  If an AB-rated generic drug that is therapeutically equivalent to
    41  the drug subject to a standing prior  authorization  becomes  available,
    42  the  health  maintenance organization may substitute such newly released
    43  drug for the drug subject to the standing prior authorization,  provided
    44  advance notice is given to the enrollee.
    45    (h)  The determination whether the drug is being prescribed to treat a
    46  chronic condition and the period over which the course of treatment  for
    47  an acute condition is anticipated to have its intended effect are utili-
    48  zation  review  decisions  and are reviewable in accordance with article
    49  forty-nine of this chapter, including external appeal.
    50    3. (a) If a formulary drug being prescribed for an enrollee is removed
    51  by the health maintenance organization from its  formulary  for  reasons
    52  other  than  a  determination that the approval for the use of that drug
    53  has been withdrawn by the U.S.  Food and Drug Administration, the health
    54  maintenance organization shall continue to  cover  that  drug  for  that
    55  enrollee  for  a  transitional period to the end of the plan year at the
    56  same copayment as charged when the drug was  on  formulary.  Thereafter,

        A. 10215                            5
 
     1  the  enrollee  may  seek continued coverage of the drug, if appropriate,
     2  pursuant to the provisions of subdivision one of this section.
     3    (b)  If  a  formulary drug being prescribed for an insured is moved by
     4  the health maintenance organization to a higher cost sharing tier in its
     5  formulary for reasons other than release of an  AB-rated  generic  drug,
     6  the  health  maintenance  organization shall continue to cover that drug
     7  for that enrollee for a transitional period to the end of the plan  year
     8  at the same copayment as charged when the drug was on formulary.  There-
     9  after,  the  enrollee may seek continued coverage of the drug, if appro-
    10  priate, pursuant to the provisions of subdivision one of this section.
    11    (c) If a health maintenance organization  that  provides  prescription
    12  drug coverage enrolls a new enrollee who is currently being prescribed a
    13  drug  for a chronic health condition, or as part of an ongoing course of
    14  treatment for an acute condition, and that drug is  not  on  the  health
    15  maintenance  organization's  formulary, the health maintenance organiza-
    16  tion shall cover that drug for that enrollee at no  additional  cost  to
    17  the  enrollee  beyond  what  the  enrollee  would  otherwise  pay  for a
    18  preferred brand name drug on the formulary, for a transitional period of
    19  ninety (90) days from the effective date  of  enrollment.  The  enrollee
    20  must  adhere  to the health maintenance organization's quality assurance
    21  requirements and provide to the health maintenance  organization  neces-
    22  sary  medical  information  related  to  the  prescription and otherwise
    23  adhere to the health maintenance organization's policies and  procedures
    24  including, but not limited to procedures regarding obtaining pre-author-
    25  ization  and  a treatment plan approved by the health maintenance organ-
    26  ization. In no event shall this subdivision be construed  to  require  a
    27  health  maintenance  organization  to  provide coverage for benefits not
    28  otherwise covered.  The transitional period does not preclude the enrol-
    29  lee from seeking continued coverage of the drug, if appropriate,  pursu-
    30  ant to the provisions of subdivision one of this section.
    31    §  3.  Section  4903  of  the insurance law is amended by adding a new
    32  subsection (i) to read as follows:
    33    (i) (1) Each health plan shall make  available  to  all  participating
    34  health  care  providers  on its web site or provider portal a listing of
    35  its prior authorization requirements, including specific information  or
    36  documentation that a provider must submit in order for the prior author-
    37  ization request to be considered complete.
    38    (2)  Each health plan shall make available on its web site information
    39  about the policies, contracts, or agreements offered by it that  clearly
    40  identifies specific services, drugs, or devices to which a prior author-
    41  ization requirement exists.
    42    (3)  Each  health  plan  shall  give  thirty (30) days advance written
    43  notice to participating providers of any changes in prior  authorization
    44  requirements.  Each health plan shall also give thirty (30) days advance
    45  written notice to plan participants of any  changes  in  prior  authori-
    46  zation requirements with respect to any services, drugs or devices which
    47  such participant is currently being prescribed or has been prescribed in
    48  the preceding year.
    49    §  4. Section 4903 of the public health law is amended by adding a new
    50  subdivision 9 to read as follows:
    51    9. (a) Each health plan shall  make  available  to  all  participating
    52  health  care  providers  on its web site or provider portal a listing of
    53  its prior authorization requirements, including specific information  or
    54  documentation that a provider must submit in order for the prior author-
    55  ization request to be considered complete.

        A. 10215                            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 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    (a) 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. 10215                            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    (b) upholding the health plan's denial of coverage.
     5    § 8. Subdivision 2 of section 4914 of the public health law is amended
     6  by adding a new paragraph (e) to read as follows:
     7    (e) For external appeals requested pursuant to paragraph (e) of subdi-
     8  vision  two  of section forty-nine hundred ten of this title relating to
     9  an off-formulary drug denial, the external appeal agent shall review the
    10  utilization review agent's final adverse determination and,  in  accord-
    11  ance with the provisions of this title, shall make a determination as to
    12  whether  the  non-formulary  drug shall be covered by the health mainte-
    13  nance organization; provided that such determination shall:
    14    (i) be conducted only by one or a greater odd number of clinical  peer
    15  reviewers;
    16    (ii) be accompanied by a written statement:
    17    (1)  that  the off-formulary drug prescription shall be covered by the
    18  health maintenance organization either when the reviewer or  a  majority
    19  of  the  panel  of  reviewers  determines,  upon review of the available
    20  medical and scientific evidence, the formulary drug deemed sufficient by
    21  the health maintenance organization will not be as effective in address-
    22  ing the enrollee's health problem for which a drug has  been  prescribed
    23  as the off-formulary drug prescribed by the treating physician or other-
    24  wise  be  appropriate  to  meet  the particular health care needs of the
    25  enrollee, which is more likely to provide a beneficial clinical outcome;
    26  or
    27    (2) upholding the health maintenance organization's denial  of  cover-
    28  age.
    29    §  9.  The  opening  paragraph  of  paragraph  28 of subsection (i) of
    30  section 3216 of the insurance law, as added by chapter 589 of  the  laws
    31  of  2011,  is  designated subparagraph (A) and a new subparagraph (B) is
    32  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. 10215                            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. The opening paragraph of subsection (kk) of section 4303 of the
     4  insurance law is designated paragraph 1 and a new paragraph 2  is  added
     5  to read as follows:
     6    (2) Notwithstanding any other provision of this subsection, if a pres-
     7  criber,  after consulting with the insurer regarding the appropriateness
     8  of mail order delivery given: (A) the residence or delivery location  of
     9  the covered person; (B) the medical condition of the covered person; (C)
    10  the  storage  requirements  of  the  drug;  (D)  the availability of the
    11  covered person to receive the prescription; or (E) the covered  person's
    12  ability to comprehend pharmaceutical guidance and support over the tele-
    13  phone,  determines  that  a drug as prescribed on an individual basis is
    14  most appropriately filled at a retail location, provided that an in-net-
    15  work retail pharmacy of  the  patient's  choosing  agrees  to  the  same
    16  reimbursement   amount  and  is  able  to  fill  the  prescription,  the
    17  prescriber's determination shall be final.
    18    § 12. The insurance law is amended by adding a new section  3224-d  to
    19  read as follows:
    20    §  3224-d. Prescription synchronization. (a) Every individual or group
    21  health insurance policy providing prescription drug coverage when appli-
    22  cable to permit synchronization shall permit and apply a daily  prorated
    23  cost-sharing rate to prescriptions that are dispensed by a network phar-
    24  macy  for  less  than  a  thirty day supply, when it is agreed among the
    25  covered individual, a health care practitioner, and  a  pharmacist  that
    26  synchronization of multiple prescriptions for the treatment of a chronic
    27  illness  is  in  the  best  interest  of  the covered individual for the
    28  management or treatment of that chronic illness provided that all of the
    29  following apply:
    30    (1) the medications are covered by the policy or plan;
    31    (2) the medications are used for treatment and management  of  chronic
    32  conditions that are subject to refills;
    33    (3)  the  medications  are not a schedule II controlled substance or a
    34  schedule III controlled substance containing hydrocodone;
    35    (4) the medications meet all prior authorization criteria specific  to
    36  medications at the time of the synchronization request;
    37    (5) the medications are of a formulation that can be effectively split
    38  over required short fill periods to achieve synchronization; and
    39    (6)  the  medications do not have quantity limits or dose optimization
    40  criteria or requirements that would be violated in fulfilling synchroni-
    41  zation.
    42    (b)  No  individual  or  group  health  insurance   policy   providing
    43  prescription  drug  coverage shall deny coverage for the dispensing of a
    44  medication for partial fill when it is for purposes of synchronizing the
    45  patient's medications. When applicable to permit synchronization,  every
    46  individual  or  group  health  insurance policy must allow a pharmacy to
    47  override any denial  codes  indicating  that  a  prescription  is  being
    48  refilled too soon for the purposes of medication synchronization.
    49    (c)  Dispensing  fees  for  partially filled or refilled prescriptions
    50  shall be paid in full for each prescription dispensed, regardless of any
    51  pro-rated copay for the beneficiary or fee paid for alignment services.
    52    (d) Nothing in this section shall be deemed  to  require  health  care
    53  practitioners  and  pharmacists to synchronize the refilling of multiple
    54  prescriptions for a covered individual.

        A. 10215                            9
 
     1    (e) The requirements of this section shall apply only  once  for  each
     2  prescription  drug  subject  to  medication  synchronization except when
     3  either of the following occurs:
     4    (1)  the  prescriber changes the dosage or frequency of administration
     5  of the prescription drug subject to a medication synchronization; or
     6    (2) the prescriber prescribes a different drug.
     7    § 13. The insurance law is amended by adding a new section  4303-a  to
     8  read as follows:
     9    §  4303-a.  Prescription  synchronization.  (a) Every hospital service
    10  corporation and health service corporation providing  prescription  drug
    11  coverage  when  applicable  to  permit  synchronization shall permit and
    12  apply a daily prorated  cost-sharing  rate  to  prescriptions  that  are
    13  dispensed  by a network pharmacy for less than a thirty day supply, when
    14  it is agreed among the covered individual, a health  care  practitioner,
    15  and  a pharmacist that synchronization of multiple prescriptions for the
    16  treatment of a chronic illness is in the best interest  of  the  covered
    17  individual  for  the  management  or  treatment  of that chronic illness
    18  provided that all of the following apply:
    19    (1) the medications are covered by the policy or plan;
    20    (2) the medications are used for treatment and management  of  chronic
    21  conditions that are subject to refills;
    22    (3)  the  medications  are not a schedule II controlled substance or a
    23  schedule III controlled substance containing hydrocodone;
    24    (4) the medications meet all prior authorization criteria specific  to
    25  medications at the time of the synchronization request;
    26    (5) the medications are of a formulation that can be effectively split
    27  over required short fill periods to achieve synchronization; and
    28    (6)  the  medications do not have quantity limits or dose optimization
    29  criteria or requirements that would be violated in fulfilling synchroni-
    30  zation.
    31    (b) No hospital service  corporation  or  health  service  corporation
    32  providing  prescription  drug  coverage  shall  deny  coverage  for  the
    33  dispensing of a medication for partial fill when it is for  purposes  of
    34  synchronizing  the  patient's  medications.  When  applicable  to permit
    35  synchronization, every hospital service corporation  or  health  service
    36  corporation  providing  prescription drug coverage must allow a pharmacy
    37  to override any denial codes indicating that  a  prescription  is  being
    38  refilled too soon for the purposes of medication synchronization.
    39    (c)  Dispensing  fees  for  partially filled or refilled prescriptions
    40  shall be paid in full for each prescription dispensed, regardless of any
    41  pro-rated copay for the beneficiary or fee paid for alignment services.
    42    (d) Nothing in this section shall be deemed  to  require  health  care
    43  practitioners  and  pharmacists to synchronize the refilling of multiple
    44  prescriptions for a covered individual.
    45    (e) The requirements of this section shall apply only  once  for  each
    46  prescription  drug  subject  to  medication  synchronization except when
    47  either of the following occurs:
    48    (1) The prescriber changes the dosage or frequency  of  administration
    49  of the prescription drug subject to a medication synchronization; or
    50    (2) The prescriber prescribes a different drug.
    51    §  14.  Subdivision  9  of section 367-a of the social services law is
    52  amended by adding a new paragraph (i) to read as follows:
    53    (i) (i) The  department  of  health  shall  establish  a  program  for
    54  synchronization  of medications when it is agreed among the recipient, a
    55  provider and a pharmacist that synchronization of multiple prescriptions
    56  for the treatment of a chronic illness is in the best  interest  of  the

        A. 10215                           10
 
     1  patient  for  the  management or treatment of a chronic illness provided
     2  that the medications:
     3    (A) are covered by the department of health pursuant to this title;
     4    (B)  are  used for treatment and management of chronic conditions that
     5  are subject to refills;
     6    (C) are not a schedule II  controlled  substance  or  a  schedule  III
     7  controlled substance containing hydrocodone;
     8    (D)  meet all prior authorization criteria specific to the medications
     9  at the time of the synchronization request;
    10    (E) are of a formulation that can be effectively split  over  required
    11  short fill periods to achieve synchronization; and
    12    (F)  do  not  have  quantity  limits  or dose optimization criteria or
    13  requirements that would be violated in fulfilling synchronization.
    14    (ii) The department of health shall not deny coverage for the dispens-
    15  ing of a medication by a network pharmacy for a partial supply  when  it
    16  is  for  the  purpose  of  synchronizing the patient's medications. When
    17  applicable to permit synchronization, the  department  of  health  shall
    18  allow  a  pharmacy  to  override  any  denial  codes  indicating  that a
    19  prescription is being refilled too soon for the purposes  of  medication
    20  synchronization.
    21    (iii)  To permit synchronization, the department of health shall apply
    22  a prorated daily cost-sharing rate to  any  medication  dispensed  by  a
    23  network pharmacy pursuant to this section.
    24    (iv)  The  dispensing  fee  paid  to  a network pharmacy contracted to
    25  provide services pursuant to this section for a partial  supply  associ-
    26  ated  with  a medication synchronization shall be paid in full and shall
    27  not be prorated.
    28    (v) The requirements of this paragraph  applies  only  once  for  each
    29  prescription  drug  subject  to  medication  synchronization except when
    30  either of the following occurs:
    31    (A) the prescriber changes the dosage or frequency  of  administration
    32  of the prescription drug subject to a medication synchronization; or
    33    (B) the prescriber prescribes a different drug.
    34    (vi)  Nothing in this paragraph shall be deemed to require health care
    35  practitioners and pharmacists to synchronize the refilling  of  multiple
    36  prescriptions for a recipient.
    37    §  15.  Subdivision  4  of section 364-j of the social services law is
    38  amended by adding a new paragraph (w) to read as follows:
    39    (w) (i) The department  of  health  or  a  managed  care  organization
    40  contracted  to provide services pursuant to this section shall establish
    41  a program for synchronization of medications when it is agreed among the
    42  recipient, a provider and a pharmacist that synchronization of  multiple
    43  prescriptions  for  the  treatment  of  a chronic illness is in the best
    44  interest of the patient for the management or  treatment  of  a  chronic
    45  illness provided that the medications:
    46    (A)  are  covered  by Medicaid services or a managed care organization
    47  contracted to provide services pursuant to this chapter;
    48    (B) are used for treatment and management of chronic  conditions  that
    49  are subject to refills;
    50    (C)  are  not  a  schedule  II  controlled substance or a schedule III
    51  controlled substance containing hydrocodone;
    52    (D) meet all prior authorization criteria specific to the  medications
    53  at the time of the synchronization request;
    54    (E)  are  of a formulation that can be effectively split over required
    55  short fill periods to achieve synchronization; and

        A. 10215                           11
 
     1    (F) do not have quantity  limits  or  dose  optimization  criteria  or
     2  requirements that would be violated in fulfilling synchronization.
     3    (ii)   The  department  of  health  or  a  managed  care  organization
     4  contracted to provide services under this section shall not deny  cover-
     5  age  for  the  dispensing  of  a  medication by a network pharmacy for a
     6  partial supply when it is for the purpose of synchronizing the patient's
     7  medications. When applicable to permit synchronization,  the  department
     8  of  health or a managed care organization contracted to provide services
     9  under this title shall allow a pharmacy  to  override  any  denial  code
    10  indicating  that  a  prescription  is  being  refilled  too soon for the
    11  purposes of medication synchronization.
    12    (iii) To permit synchronization, the department of health or a managed
    13  care organization contracted to provide services pursuant to this  title
    14  shall  apply  a  prorated  daily  cost-sharing  rate  to  any medication
    15  dispensed by a network pharmacy pursuant to this section.
    16    (iv) The dispensing fee paid  to  a  network  pharmacy  contracted  to
    17  provide  services  pursuant to this section for a partial supply associ-
    18  ated with a medication synchronization shall be paid in full  and  shall
    19  not be prorated.
    20    (v)  The  requirements  of  this  paragraph applies only once for each
    21  prescription drug subject  to  medication  synchronization  except  when
    22  either of the following occurs:
    23    (A)  the  prescriber changes the dosage or frequency of administration
    24  of the prescription drug subject to a medication synchronization; or
    25    (B) the prescriber prescribes a different drug.
    26    (vi) Nothing in this paragraph shall be deemed to require health  care
    27  practitioners  and  pharmacists to synchronize the refilling of multiple
    28  prescriptions for a covered individual.
    29    § 16. Section 280-a of the public health law is amended by adding  two
    30  new subdivisions 3 and 4 to read as follows:
    31    3.  No  pharmacy  benefit  manager  shall,  with  respect to contracts
    32  between such pharmacy benefit manager and a pharmacy or,  alternatively,
    33  such  pharmacy  benefit manager and a pharmacy's contracting agent, such
    34  as a pharmacy services administrative organization:
    35    (a) prohibit or penalize a pharmacist or pharmacy from  disclosing  to
    36  an  individual  purchasing a prescription medication information regard-
    37  ing:
    38    (i) the cost of the prescription medication to the individual; or
    39    (ii) the availability of any  therapeutically  equivalent  alternative
    40  medications  or alternative methods of purchasing the prescription medi-
    41  cation, including but not limited to, paying a cash price; or
    42    (b) charge or collect from an individual a copayment that exceeds  the
    43  total  submitted charges by the pharmacy for which the pharmacy paid. If
    44  an individual pays a copayment, the pharmacy shall  retain  the  adjudi-
    45  cated  costs and the pharmacy benefit manager shall not redact or recoup
    46  the adjudicated cost.
    47    4. Any provision of a contract that violates the  provisions  of  this
    48  section shall be deemed to be void and unenforceable.
    49    § 17. Subsection (h) of section 4325 of the insurance law, as added by
    50  chapter 487 of the laws of 2010, is amended to read as follows:
    51    (h)  (i)  No  corporation  or insurer organized or licensed under this
    52  chapter which provides coverage for prescription drugs shall require, or
    53  enter into a contract which permits, a copayment which exceeds the usual
    54  and customary cost of such prescribed drug or which  exceeds  the  total
    55  price  paid  to  the pharmacy for such prescribed drug after the insured
    56  has met the annual deductible requirement.

        A. 10215                           12
 
     1    (ii) In determining any coinsurance amount required to be paid  for  a
     2  prescription  drug, no insurer or corporation organized under this chap-
     3  ter shall base its computation on a price higher than the  actual  price
     4  paid  by  the  pharmacy  for  the  drug, taking into account any rebates
     5  specific  to  the drug. The department of financial services shall issue
     6  regulations setting forth the method each insurer or corporation  organ-
     7  ized  under  this chapter must use to determine the actual price paid by
     8  the pharmacy.
     9    (iii) Each insurer or corporation licensed under  this  article  which
    10  offers  prescription  drug  coverage must itself or through its pharmacy
    11  benefit manager issue a written  explanation  of  benefit  form  to  its
    12  enrollees with respect to each prescription filled, containing all cate-
    13  gories  of  information  required  of  explanation of benefits forms for
    14  medical benefits.
    15    § 18. Subdivision 6 of section 6810 of the education law is amended by
    16  adding a new paragraph (b-1) to read as follows:
    17    (b-1) The prescriber or pharmacist shall inform the patient whether he
    18  or she has prescribed or substituted a different  generic  drug  product
    19  from  the  generic  drug  product  the  patient has previously received.
    20  Notification required pursuant to this paragraph shall be provided  both
    21  written   and   orally,   contemporaneously  with  the  filling  of  the
    22  prescription.
    23    § 19. Section 6826-a of the education law is amended by adding  a  new
    24  subdivision 3 to read as follows:
    25    3.  The  copayment amount shall not exceed the total price paid to the
    26  pharmacy for the prescribed drug, except in cases where the insured  has
    27  not  met  the  annual deductible requirement. The copayment charged to a
    28  consumer for a prescription drug shall not exceed the amount which would
    29  be charged if the drug were purchased without insurance coverage.
    30    § 20. Paragraph 1 of subsection (e) of section 3231 of  the  insurance
    31  law is amended by adding a new subparagraph (C) to read as follows:
    32    (C)  an  insurer shall annually certify to the department that, during
    33  the prior benefit year, the insurer made available to enrollees  at  the
    34  point  of sale at least a majority (i.e., greater than fifty percent) of
    35  the rebates.
    36    (i) For purposes of this subparagraph, "rebate" means:
    37    (1) negotiated price concessions including but  not  limited  to  base
    38  rebates  and  reasonable  estimates  of any price protection rebates and
    39  performance-based rebates that may accrue directly or indirectly to  the
    40  issuer  during the coverage year from a manufacturer, dispensing pharma-
    41  cy, or other party to the transaction; and
    42    (2) reasonable estimates of any fees and  other  administrative  costs
    43  that  are  passed through to the issuer and serve to reduce the issuer's
    44  prescription drug liabilities for the coverage year.
    45    (ii) In providing the certification required under  this  section,  an
    46  issuer  shall  not publish or otherwise reveal information regarding the
    47  actual amount of rebates the issuer received on a product-,  manufactur-
    48  er-,  or  pharmacy-specific  basis.   Such information is protected as a
    49  trade secret, is not a public record as defined in the  public  officers
    50  law  and shall not be disclosed directly or indirectly. An insurer shall
    51  impose the confidentiality protections of  this  section  on  any  third
    52  parties  or  vendors  with  which  it contracts that may receive or have
    53  access to rebate information.
    54    § 21. Subsection (b) of section 3221 of the insurance law  is  amended
    55  to read as follows:

        A. 10215                           13
 
     1    (b)  (1)  No  such policy shall be delivered or issued for delivery in
     2  this state unless a schedule of the premium  rates  pertaining  to  such
     3  form shall have been filed with the superintendent.
     4    (2)  An  insurer shall annually certify to the department that, during
     5  the prior benefit year, the insurer made available to enrollees  at  the
     6  point  of sale at least a majority (i.e., greater than fifty percent) of
     7  the rebates.
     8    (A) For purposes of this paragraph, "rebate" means:
     9    (i) Negotiated price concessions including but  not  limited  to  base
    10  rebates  and  reasonable  estimates  of any price protection rebates and
    11  performance-based rebates that may accrue directly or indirectly to  the
    12  issuer  during the coverage year from a manufacturer, dispensing pharma-
    13  cy, or other party to the transaction; and
    14    (ii) Reasonable estimates of any fees and other  administrative  costs
    15  that  are  passed through to the issuer and serve to reduce the issuer's
    16  prescription drug liabilities for the coverage year.
    17    (B) In providing the certification required  under  this  section,  an
    18  issuer  shall  not publish or otherwise reveal information regarding the
    19  actual amount of rebates the issuer received on a product-,  manufactur-
    20  er-,  or  pharmacy-specific  basis.   Such information is protected as a
    21  trade secret, is not a public record as defined in the  public  officers
    22  law  and shall not be disclosed directly or indirectly. An insurer shall
    23  impose the confidentiality protections of  this  section  on  any  third
    24  parties  or  vendors  with  which  it contracts that may receive or have
    25  access to rebate information.
    26    § 22. Severability.  If  any  item,  clause,  sentence,  subparagraph,
    27  subdivision or other part of this act, or the application thereof to any
    28  person  or circumstances shall be held to be invalid, such holding shall
    29  not affect, impair or invalidate the remainder of this act but it  shall
    30  be  confined  in  its  operation to the item, clause, sentence, subpara-
    31  graph, subdivision or other part of this act directly involved  in  such
    32  holding, or to the person and circumstances therein involved.
    33    § 23. This act shall take effect immediately and shall apply to insur-
    34  ance  policies  issued, amended, or renewed on or after January 1, 2019;
    35  provided, however, that the amendments to subdivision 9 of section 367-a
    36  of the social services law made by section fourteen of  this  act  shall
    37  not  affect  the expiration of such subdivision pursuant to section 4 of
    38  chapter 19 of the laws of 1998, as amended, and shall expire  therewith;
    39  and  provided,  further,  that  the  amendments  to section 364-j of the
    40  social services law made by section fifteen of this act shall not affect
    41  the repeal of such section  and  shall  be  deemed  repealed  therewith.
    42  Effective  immediately  the addition, amendment or repeal of any rule or
    43  regulation necessary for the implementation of this act on its effective
    44  date are authorized to be made on or before such date.
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