A02834 Summary:

COSPNSRGottfried, Rodriguez, Gunther, Zebrowski, Quart, Peoples-Stokes, Montesano, Cusick, Brindisi, Tedisco, Weprin, Rosenthal, Skoufis, Rozic, Johns, Jaffee, Stirpe, Steck, Otis, Abinanti, Barrett, Thiele, Pichardo, Kearns, Santabarbara, Colton, Crouch, Hunter, Paulin, Cook, Cymbrowitz, Joyner, Lavine, Castorina, Dilan, McDonald, Moya, Braunstein, Seawright, Raia, Woerner, Magnarelli, Blake, Solages, Walter, Lawrence, Simon, Harris
MLTSPNSRBuchwald, Ceretto, Crespo, Duprey, Englebright, Fahy, Friend, Galef, Glick, Hevesi, Hooper, Kolb, Lentol, Lupardo, Lupinacci, Markey, McDonough, McLaughlin, Murray, Oaks, Perry, Ra, Rivera, Schimel, Sepulveda, Tenney
Amd §§3217-a, 4324, 4900, 4902 & 4903, Ins L; amd §§4408, 4900, 4902 & 4903, Pub Health L
Relates to expedited utilization review of prescription drugs.
Go to top    

A02834 Actions:

01/20/2015referred to insurance
05/07/2015amend (t) and recommit to insurance
05/07/2015print number 2834a
01/06/2016referred to insurance
02/29/2016amend and recommit to insurance
02/29/2016print number 2834b
05/27/2016amend (t) and recommit to insurance
05/27/2016print number 2834c
06/01/2016reported referred to rules
06/07/2016amend and recommit to rules 2834d
06/14/2016rules report cal.266
06/14/2016substituted by s3419c
 05/06/2015PRINT NUMBER 3419A
 03/16/2016PRINT NUMBER 3419B
 06/07/2016PRINT NUMBER 3419C
 06/14/2016PASSED SENATE
 06/14/2016referred to insurance
 06/14/2016substituted for a2834d
 06/14/2016ordered to third reading rules cal.266
 06/16/2016passed assembly
 06/16/2016returned to senate
 12/31/2016APPROVAL MEMO.30
 12/31/2016SIGNED CHAP.512
Go to top

A02834 Memo:

submitted in accordance with Assembly Rule III, Sec 1(f)
SPONSOR: Titone (MS)
  TITLE OF BILL: An act to amend the insurance law and the public health law, in relation to expedited utilization review of prescription drugs   PURPOSE OR GENERAL IDEA OF BILL: The purpose of this bill is to regulate insurance companies, health maintenance organizations (HMOs), and utilization review agents who impose step therapy protocols on patients and to provide for an expe- dited appeals process for patients and their health care professionals to override such protocols.   SUMMARY OF SPECIFIC PROVISIONS: Sections 1 and 2 amend Section 3217-a (b)(10) and Section 4324 (b) (10) of the Insurance Law to require health insurance companies to provide patients and health care professionals with specific written information on their clinical review criteria relating to a decision made to utilize a step therapy protocol for a particular patient. Section 3 amends Section 4900 of the Insurance Law to define key terms such as "Step therapy protocol override determination" and "Step therapy protocol." Step therapy protocol means a policy, protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition are approved for a particular patient. Step therapy protocol override determination means a determination made by a utilization review agent to override a step therapy protocol. Section 4 amends Section 4902 (a) of the Insurance Law by adding a two new subdivisions (10) and (11). Subdivision 10 requires a utilization review agent to utilize evidenced-based and peer reviewed clinical review criteria that is appropriate for a patient's medical condition when establishing a step therapy protocol. Subdivision 11 requires a utilization review agent to utilize evidence-based and peer reviewed clinical review criteria that is appropriate to a particular patient and such patient's medical condition when making a determination about whether to override a step therapy protocol. Section 5 adds three new subsections (c-1), (c-2) and (c-3) to the Insurance Law to provide an expedited process for patients and health care providers to override a step therapy protocol. A determination must be made within 72 hours of the receipt of all information from the patient and/or health care provider in emergency cases. This section establishes standards for an override determination. Upon a determi- nation that the step therapy protocol should be overridden, the health plan must authorize immediate coverage for the prescription drug prescribed by the patient's treating health care provider. Section 6 amends Section 4903 (g) of the Insurance Law to provide that if an insurance company or utilization review agent fails to respond within the required timeframes, the appeal shall be deemed granted in favor of the patient. Sections 7, 8, 9, 10 and 11 make identical amendments as those described above to the Public Health Law to regulate step therapy or fail first protocols imposed by HMOs. Section 12 is an amendment of the Unconsolidated Laws to provide that the bill shall not be construed to prevent: a health care plan, utiliza- tion review agent, or pharmacy benefit manager from requiring a patient to try an AB-rated generic equivalent prior to providing coverage for the equivalent branded prescription drug; or a health care provider from prescribing a prescription drug that is determined to be medically appropriate. Section 13 provides for an effective date of January 1, 2017 applicable to health insurance and health benefit plans delivered, issued for delivery, or renewed after such date.   JUSTIFICATION: The Legislature makes the following findings: (1) Health insurance plans are increasingly making use of step therapy or "fail first" protocols under which patients are required to try one or more prescription drugs before coverage is provided for a drug selected by the patient's health care provider. (2) Step therapy protocols, where they are based on well-developed scientific standards and administered in a flexible manner that takes into account the individual needs of patients, can play an important role in controlling health care costs. (3) In some cases, requiring a patient to follow a step therapy protocol may have adverse and even dangerous consequences for the patient who may either not realize a benefit from taking a prescription drug or may suffer harm from taking an inappropriate drug. (4) Without uniform policies in the State for step therapy protocols, all patients may not receive the equivalent or most appropriate treat- ment. (5) It is imperative that step therapy protocols in the State preserve the health care provider's right to make treatment decisions in the best interests of the patient. (6) Therefore, it is a matter of public interest to require health insurance companies and utilization review organizations to base step therapy protocols on appropriate clinical practice guidelines or published peer review data developed by independent experts with know- ledge of the condition or conditions under consideration; that patients be exempt from step therapy protocols when inappropriate or otherwise not in the best interest of the patients; and that patients have access to a fair, transparent and independent process for requesting an excep- tion to a step therapy protocol when the patients' physician deems appropriate. The following states have enacted strong laws to prohibit or limit step therapy or fail first practices: Connecticut, Kentucky, Louisiana, Mary- land, Mississippi, Indiana and Washington. Patients in New York current- ly subject to step therapy or fail first practices require similar protections.   PRIOR LEGISLATIVE HISTORY: (2011-12) A.9397 Referred to Insurance (2013-14) A5124 Referred to Insurance   FISCAL IMPLICATIONS: Undetermined at this time.   EFFECTIVE DATE: The act would take effect on January 1, 2017 and apply to health insur- ance and health benefit plans delivered, issued for delivery, or renewed after such date.
Go to top