STATE OF NEW YORK
________________________________________________________________________
10293
IN ASSEMBLY
May 20, 2016
___________
Introduced by M. of A. JOYNER -- read once and referred to the Committee
on Insurance
AN ACT to amend the insurance law, in relation to reimbursements to mail
order pharmacies
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Paragraphs 13-a and 28 of subsection (i) of section 3216 of
2 the insurance law, paragraph 13-a as amended by chapter 10 of the laws
3 of 2012, paragraph 28 as amended by chapter 11 of the laws of 2012, are
4 amended to read as follows:
5 (13-a) (A) Definitions. For the purposes of this paragraph:
6 (1) "Same reimbursement amount" shall mean that any coverage described
7 under subparagraph (B) of this paragraph shall provide the same bench-
8 mark index, including the same average wholesale price, maximum allow-
9 able cost and national prescription drug codes to reimburse all pharma-
10 cies participating in the insurance network regardless of whether a
11 pharmacy is a mail order pharmacy or a non-mail order pharmacy.
12 (2) "Mail order pharmacy" shall mean a pharmacy whose primary business
13 is to receive prescriptions by mail, telefax or through electronic
14 submissions and to dispense medication to patients through the use of
15 the United States mail or other common or contract carrier services and
16 provides any consultation with patients electronically rather than face-
17 to-face.
18 (3) "Standard terms and conditions" shall mean the contractual terms
19 and conditions applicable to all network participating pharmacies that
20 were in effect on June first, two thousand fifteen; provided that if an
21 insurer has established different standard terms and conditions for mail
22 order pharmacies and non-mail order retail pharmacies, the term "stand-
23 ard terms and conditions" shall mean the standard terms and conditions
24 that were in effect on June first, two thousand fifteen for non-mail
25 order retail pharmacies, and provided further that any such standard
26 terms and conditions that require:
27 (i) consultation with a pharmacist shall not require such consultation
28 be available at non-mail order pharmacies outside of such pharmacy's
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD15299-04-6
A. 10293 2
1 regular hours of operation and shall require mail order pharmacies to
2 provide such consultation twenty-four hours a day, seven days a week;
3 (ii) specific storage size for prescription drugs requiring special
4 handling, such as refrigeration, shall be based on the contracting phar-
5 macy's dispensing experience and shall not require a pharmacy to
6 increase its storage space when it has not been established that such
7 pharmacy's prescription volume requires such increased storage; and
8 (iii) specific storage space for prescription drugs that do not
9 require special handling shall be based on the contracting pharmacy's
10 physical size and dispensing experience and shall not require a pharmacy
11 to increase its storage space when it has not been established that such
12 pharmacy's prescription volume requires such increased storage.
13 (B) Every policy that provides coverage for prescription fertility
14 drugs and requires or permits prescription drugs to be purchased through
15 a network participating mail order or other non-retail pharmacy shall
16 provide the same coverage for prescription fertility drugs and shall not
17 limit the supply that may be dispensed to a thirty-day supply when such
18 drugs are purchased from a network participating non-mail order retail
19 pharmacy provided that the network participating non-mail order retail
20 pharmacy agrees [in advance through a contractual network agreement,] to
21 the same reimbursement amount[, as well as the same applicable terms and
22 conditions,] and standard terms and conditions that the insurer has
23 established for [a] network participating [mail order or other non-re-
24 tail pharmacy] pharmacies. In such case, the policy shall not impose
25 any fee, co-payment, co-insurance, deductible or other condition,
26 including requiring monthly refills of a prescription that was written
27 for and may be filled for more than a thirty-day supply, on any insured
28 who elects to purchase prescription fertility drugs through a network
29 participating non-mail order retail pharmacy that it does not impose on
30 any insured who purchases prescription fertility drugs through a network
31 participating mail order or other non-retail pharmacy.
32 (C) Any policy that provides coverage for prescription fertility drugs
33 shall, in addition to the standard terms and conditions, require mail
34 order pharmacies to replace dispensed prescription fertility drugs for
35 which the mail or carrier service has proof of delivery that have not
36 been received by the insured, or are spoiled or damaged, provided that
37 in the case of a prescription fertility drug that has not been received
38 by the insured, the policy may require that the insured provide proof of
39 theft in the form of a filed police report reporting the theft and in
40 the case of a damaged or spoiled prescription fertility drug, the policy
41 may require that the damaged prescription fertility drug be returned to
42 the mail order pharmacy with the cost to be borne by such pharmacy, and
43 provided further that such unreceived, spoiled or damaged prescription
44 fertility drug shall be replaced before receipt of the police report or
45 the returned, spoiled or damaged prescription fertility drug, as the
46 case may be. If such required police report is not provided or the
47 damaged or spoiled prescription fertility drug is not returned, the
48 policy may require the insured to reimburse the policy for the cost of
49 the prescription fertility drug and, notwithstanding the forgoing, when
50 an insured who was previously required to reimburse the plan for a
51 dispensed prescription fertility drug that was not received by the
52 insured, or was damaged or spoiled, the policy may refuse to replace
53 such prescription fertility drug for such insured until such insured has
54 provided the plan with the required police report or returned the
55 spoiled or damaged prescription fertility drug. Replacement of a
A. 10293 3
1 prescription fertility drug pursuant to this subparagraph shall not be
2 limited to a specific number of occurrences during a contract year.
3 (28) (A) Definitions. For the purposes of this paragraph:
4 (1) "Same reimbursement amount" shall mean that any coverage described
5 under subparagraph (B) of this paragraph shall provide the same bench-
6 mark index, including the same average wholesale price, maximum allow-
7 able cost and national prescription drug codes to reimburse all pharma-
8 cies participating in the insurance network regardless of whether a
9 pharmacy is a mail order pharmacy or a non-mail order pharmacy.
10 (2) "Mail order pharmacy" shall mean a pharmacy whose primary business
11 is to receive prescriptions by mail, telefax or through electronic
12 submissions and to dispense medication to patients through the use of
13 the United States mail or other common or contract carrier services and
14 provides any consultation with patients electronically rather than face-
15 to-face.
16 (3) "Standard terms and conditions" shall mean the contractual terms
17 and conditions applicable to all network participating pharmacies that
18 were in effect on June first, two thousand fifteen; provided that if an
19 insurer has established different standard terms and conditions for mail
20 order pharmacies and non-mail order retail pharmacies, the term "stand-
21 ard terms and conditions" shall mean the standard terms and conditions
22 that were in effect on June first, two thousand fifteen for non-mail
23 order retail pharmacies, and provided further that any such standard
24 terms and conditions that require:
25 (i) consultation with a pharmacist shall not require such consultation
26 be available at non-mail order pharmacies outside of such pharmacy's
27 regular hours of operation and shall require mail order pharmacies to
28 provide such consultation twenty-four hours a day, seven days a week;
29 (ii) specific storage size for prescription drugs requiring special
30 handling, such as refrigeration, shall be based on the contracting phar-
31 macy's dispensing experience and shall not require a pharmacy to
32 increase its storage space when it has not been established that such
33 pharmacy's prescription volume requires such increased storage; and
34 (iii) specific storage space for prescription drugs that do not
35 require special handling shall base such requirements on the contracting
36 pharmacy's physical size and dispensing experience and shall not require
37 a pharmacy to increase its storage space when it has not been estab-
38 lished that such pharmacy's prescription volume requires such increased
39 storage.
40 (B) Any policy that provides coverage for prescription drugs shall
41 permit each insured to fill any covered prescription that may be
42 obtained at a network participating mail order or other non-retail phar-
43 macy, at the insured's option, at a network participating non-mail order
44 retail pharmacy provided that the network participating non-mail order
45 retail pharmacy agrees [in advance, through a contractual network agree-
46 ment,] to the same reimbursement amount[, as well as the same applicable
47 terms and conditions,] and standard terms and conditions that the insur-
48 er has established for the network participating [mail order or other
49 non-retail pharmacy] pharmacies. In such a case, the policy shall not
50 impose a co-payment fee or other condition, including requiring monthly
51 refills of a prescription that was written for and may be filled for
52 more than a thirty-day supply, on any insured who elects to purchase
53 prescription drugs from a network participating non-mail order retail
54 pharmacy which is not also imposed on insureds electing to purchase
55 drugs from a network participating mail order or other non-retail phar-
56 macy.
A. 10293 4
1 (C) Any policy that provides coverage for prescription drugs shall, in
2 addition to the standard terms and conditions, require mail order phar-
3 macies to replace dispensed prescription drugs for which the mail or
4 carrier service has proof of delivery that have not been received by the
5 insured, or are spoiled or damaged, provided that in the case of a
6 prescription drug that has not been received by the insured, the policy
7 may require that the insured provide proof of theft in the form of a
8 filed police report reporting the theft and in the case of a damaged or
9 spoiled prescription drug, the policy may require that the damaged
10 prescription drug be returned to the mail order pharmacy with the cost
11 to be borne by such pharmacy, and provided further that such unreceived,
12 spoiled or damaged prescription drug shall be replaced before receipt of
13 the police report or the spoiled or damaged prescription drug, as the
14 case may be. If such required police report is not provided or the
15 damaged or spoiled prescription drug is not returned, the policy may
16 require the insured to reimburse the policy for the cost of the
17 prescription drug and, notwithstanding the forgoing, when an insured who
18 was previously required to reimburse the plan for a dispensed
19 prescription drug that was not received by the insured, or was damaged
20 or spoiled, the policy may refuse to replace such prescription drug for
21 such insured until such insured has provided the plan with the required
22 police report or retuned the spoiled or damaged prescription drug.
23 Replacement of a prescription drug pursuant to this subparagraph shall
24 not be limited to a specific number of occurrences during a contract
25 year.
26 § 2. Subparagraph (D) of paragraph 6 of subsection (k) of section 3221
27 of the insurance law, as amended by chapter 10 of the laws of 2012, is
28 amended to read as follows:
29 (D) (i) Definitions. For the purpose of this paragraph:
30 (1) "Same reimbursement amount" shall mean that any coverage described
31 under item (ii) of this subparagraph shall provide the same benchmark
32 index, including the same average wholesale price, maximum allowable
33 cost and national prescription drug codes to reimburse all pharmacies
34 participating in the insurance network regardless of whether a pharmacy
35 is a mail order pharmacy or a non-mail order pharmacy.
36 (2) "Mail order pharmacy" shall mean a pharmacy whose primary business
37 is to receive prescriptions by mail, telefax or through electronic
38 submissions and to dispense medication to patients through the use of
39 the United States mail or other common or contract carrier services and
40 provides any consultation with patients electronically rather than face-
41 to-face.
42 (3) "Standard terms and conditions" shall mean the contractual terms
43 and conditions applicable to all network participating pharmacies that
44 were in effect on June first, two thousand fifteen; provided that if an
45 insurer has established different standard terms and conditions for mail
46 order pharmacies and non-mail order retail pharmacies, the term standard
47 terms and conditions shall mean the standard terms and conditions that
48 were in effect on June first, two thousand fifteen for non-mail order
49 retail pharmacies, and provided further that any such standard terms and
50 conditions that require:
51 a. Consultation with a pharmacist shall not require such consultation
52 be available at non-mail order pharmacies outside of such pharmacy's
53 regular hours of operation and shall require mail order pharmacies to
54 provide such consultation twenty-four hours a day, seven days a week;
55 b. Specific storage size for prescription drugs requiring special
56 handling, such as refrigeration, shall be based on the contracting phar-
A. 10293 5
1 macy's dispensing experience and shall not require a pharmacy to
2 increase its storage space when it has not been established that such
3 pharmacy's prescription volume requires such increased storage; and
4 c. Specific storage space for prescription drugs that do not require
5 special handling shall be based on the contracting pharmacy's physical
6 size and dispensing experience and shall not require a pharmacy to
7 increase its storage space when it has not been established that such
8 pharmacy's prescription volume requires such increased storage.
9 (ii) Every policy that provides coverage for prescription fertility
10 drugs and requires or permits prescription drugs to be purchased through
11 a network participating mail order or other non-retail pharmacy shall
12 provide the same coverage for prescription fertility drugs and shall not
13 limit the supply that may be dispensed to a thirty-day supply when such
14 drugs are purchased from a network participating non-mail order retail
15 pharmacy provided that the network participating non-mail order retail
16 pharmacy agrees [in advance through a contractual network agreement,] to
17 the same reimbursement amount[, as well as the same applicable terms and
18 conditions,] and standard terms and conditions that the insurer has
19 established for [a] network participating [mail order or other non-re-
20 tail pharmacy] pharmacies. In such case, the policy shall not impose any
21 fee, co-payment, co-insurance, deductible or other condition, including
22 requiring monthly refills of a prescription that was written for and may
23 be filled for more than a thirty-day supply, on any covered person who
24 elects to purchase prescription fertility drugs through a network
25 participating non-mail order retail pharmacy that it does not impose on
26 any covered person who purchases prescription fertility drugs through a
27 network participating mail order or other non-retail pharmacy; provided,
28 however, that the provisions of this section shall not supersede the
29 terms of a collective bargaining agreement or apply to a policy that is
30 the result of a collective bargaining agreement between an employer and
31 a recognized or certified employee organization.
32 (iii) Any policy that provides coverage for prescription fertility
33 drugs shall, in addition to the standard terms and conditions, require
34 mail order pharmacies to replace dispensed prescription fertility drugs
35 for which the mail or carrier service has proof of delivery that have
36 not been received by the insured, or are spoiled or damaged, provided
37 that in the case of a prescription fertility drug that has not been
38 received by the insured, the policy may require that the insured provide
39 proof of theft in the form of a filed police report reporting the theft
40 and in the case of a damaged or spoiled prescription fertility drug, the
41 policy may require that the damaged prescription fertility drug be
42 returned to the mail order pharmacy with the cost to be borne by such
43 pharmacy, and provided further that such unreceived, spoiled or damaged
44 prescription fertility drug shall be replaced before receipt of the
45 police report or the returned spoiled or damaged prescription fertility
46 drug, as the case may be. If such required police report is not provided
47 or the damaged or spoiled prescription fertility drug is not returned,
48 the policy may require the insured to reimburse the policy for the cost
49 of the prescription fertility drug and, notwithstanding the forgoing,
50 when an insured who was previously required to reimburse the plan for a
51 dispensed prescription fertility drug that was not received by the
52 insured, or was damaged or spoiled, the policy may refuse to replace
53 such prescription fertility drug for such insured until such insured has
54 provided the plan with the required police report or returned the
55 spoiled or damaged prescription fertility drug. Replacement of a
A. 10293 6
1 prescription fertility drug pursuant to this clause shall not be limited
2 to a specific number of occurrences during a contract year.
3 § 3. Paragraph 18 of subsection (l) of section 3221 of the insurance
4 law, as amended by chapter 11 of the laws of 2012, is amended to read as
5 follows:
6 (18) (A) Definitions. For the purpose of this paragraph:
7 (1) "Same reimbursement amount" shall mean that any coverage described
8 under subparagraph (B) of this paragraph shall provide the same bench-
9 mark index, including the same average wholesale price, maximum allow-
10 able cost and national prescription drug codes to reimburse all pharma-
11 cies participating in the insurance network regardless of whether a
12 pharmacy is a mail order pharmacy or a non-mail order pharmacy.
13 (2) "Mail order pharmacy" shall mean a pharmacy whose primary business
14 is to receive prescriptions by mail, telefax or through electronic
15 submissions and to dispense medication to patients through the use of
16 the United States mail or other common or contract carrier services and
17 provides any consultation with patients electronically rather than face-
18 to-face.
19 (3) "Standard terms and conditions" shall mean the contractual terms
20 and conditions applicable to all network participating pharmacies that
21 were in effect on June first, two thousand fifteen; provided that if an
22 insurer has established different standard terms and conditions for mail
23 order pharmacies and non-mail order retail pharmacies, the term standard
24 terms and conditions shall mean the standard terms and conditions that
25 were in effect on June first, two thousand fifteen for non-mail order
26 retail pharmacies, and provided further that any such standard terms and
27 conditions that require:
28 (i) Consultation with a pharmacist shall not require such consultation
29 be available at non-mail order pharmacies outside of such pharmacy's
30 regular hours of operation and shall require mail order pharmacies to
31 provide such consultation twenty-four hours a day, seven days a week;
32 (ii) Specific storage size for prescription drugs requiring special
33 handling, such as refrigeration, shall be based on the contracting phar-
34 macy's dispensing experience and shall not require a pharmacy to
35 increase its storage space when it has not been established that such
36 pharmacy's prescription volume requires such increased storage; and
37 (iii) Specific storage space for prescription drugs that do not
38 require special handling shall base such requirements on the contracting
39 pharmacy's physical size and dispensing experience and shall not require
40 a pharmacy to increase its storage space when it has not been estab-
41 lished that such pharmacy's prescription volume requires such increased
42 storage.
43 (B) Any insurer delivering a group or blanket policy or issuing a
44 group or blanket policy for delivery in this state that provides cover-
45 age for prescription drugs shall permit each insured to fill any covered
46 prescription that may be obtained at a network participating mail order
47 or other non-retail pharmacy, at the insured's option, at a network
48 participating non-mail order retail pharmacy provided that the network
49 participating non-mail order retail pharmacy [agrees in advance, through
50 a contractual network agreement,] to the same reimbursement amount[, as
51 well as the same applicable terms and conditions,] and standard terms
52 and conditions that the insurer has established for the network partic-
53 ipating [mail order or other non-retail pharmacy] pharmacies. In such a
54 case, the policy shall not impose a co-payment fee or other condition,
55 including requiring monthly refills of a prescription that was written
56 for and may be filled for more than a thirty-day supply, on any insured
A. 10293 7
1 who elects to purchase drugs from a network participating non-mail order
2 retail pharmacy which is not also imposed on insureds electing to
3 purchase drugs from a network participating mail order or other non-re-
4 tail pharmacy; provided, however, that the provisions of this section
5 shall not supersede the terms of a collective bargaining agreement or
6 apply to a policy that is the result of a collective bargaining agree-
7 ment between an employer and a recognized or certified employee organ-
8 ization.
9 (C) Any policy that provides coverage for prescription drugs shall, in
10 addition to the standard terms and conditions, require mail order phar-
11 macies to replace dispensed prescription drugs for which the mail or
12 carrier service has proof of delivery that have not been received by the
13 insured, or are spoiled or damaged, provided that in the case of a
14 prescription drug that has not been received by the insured, the policy
15 may require that the insured provide proof of theft in the form of a
16 filed police report reporting the theft and in the case of a damaged or
17 spoiled prescription drug, the policy may require that the damaged
18 prescription drug be returned to the mail order pharmacy with the cost
19 to be borne by such pharmacy, and provided further that such unreceived,
20 spoiled or damaged prescription drug shall be replaced before receipt of
21 the police report or the spoiled or damaged prescription drug, as the
22 case may be. If such required police report is not provided or the
23 damaged or spoiled prescription drug is not returned, the policy may
24 require the insured to reimburse the policy for the cost of the
25 prescription drug and, notwithstanding the forgoing, when an insured who
26 was previously required to reimburse the plan for a dispensed
27 prescription drug that was not received by the insured, or was damaged
28 or spoiled, the policy may refuse to replace such prescription drug for
29 such insured until such insured has provided the plan with the required
30 police report or returned the spoiled or damaged prescription drug.
31 Replacement of a prescription drug pursuant to this subparagraph shall
32 not be limited to a specific number of occurrences during a contract
33 year.
34 § 4. Paragraph 4 of subsection (s) of section 4303 of the insurance
35 law, as amended by chapter 10 of the laws of 2012, is amended to read as
36 follows:
37 (4) (A) Definition. For the purpose of this paragraph:
38 (i) "Same reimbursement amount" shall mean that any coverage described
39 under subparagraph (B) of this subsection shall provide the same bench-
40 mark index, including the same average wholesale price, maximum allow-
41 able cost and national prescription drug codes to reimburse all pharma-
42 cies participating in the insurance network regardless of whether a
43 pharmacy is a mail order pharmacy or a non-mail order pharmacy.
44 (ii) "Mail order pharmacy" shall mean a pharmacy whose primary busi-
45 ness is to receive prescriptions by mail, telefax or through electronic
46 submissions and to dispense medication to patients through the use of
47 the United States mail or other common or contract carrier services and
48 provides any consultation with patients electronically rather than face-
49 to-face.
50 (iii) "Standard terms and conditions" shall mean the contractual terms
51 and conditions applicable to all network participating pharmacies that
52 were in effect on June first, two thousand fifteen; provided that if an
53 insurer had established different standard terms and conditions for mail
54 order pharmacies and non-mail order retail pharmacies, the term standard
55 terms and conditions shall mean the standard terms and conditions that
56 were in effect on June first, two thousand fifteen for non-mail order
A. 10293 8
1 retail pharmacies, and provided further that any such standard terms and
2 conditions that require:
3 (I) Consultation with a pharmacist shall not require such consultation
4 be available at non-mail order pharmacies outside of such pharmacy's
5 regular hours of operation and shall require mail order pharmacies to
6 provide such consultation twenty-four hours a day, seven days a week;
7 (II) Specific storage space for prescription drugs require special
8 handling, such as refrigeration, shall be based on the contracting phar-
9 macy's dispensing experience and shall not require a pharmacy to
10 increase its storage space when it has not been established that such
11 pharmacy's prescription volume requires such increased storage; and
12 (III) Specific storage space for prescription drugs that do not
13 require special handling shall be based on on the contracting pharmacy's
14 physical size and dispensing experience and shall not require a pharmacy
15 to increase its storage space when it has not been established that such
16 pharmacy's prescription volume requires such increased storage.
17 (B) Every contract issued by a medical expense indemnity corporation,
18 a hospital service corporation or a health services corporation that
19 provides coverage for prescription fertility drugs and requires or
20 permits prescription drugs to be purchased through a network participat-
21 ing mail order or other non-retail pharmacy shall provide the same
22 coverage for prescription fertility drugs and shall not limit the supply
23 that may be dispensed to a thirty-day supply when such drugs are
24 purchased from a network participating non-mail order retail pharmacy
25 provided that the network participating non-mail order retail pharmacy
26 agrees [in advance, through a contractual network agreement,] to the
27 same reimbursement amount[, as well as the same applicable terms and
28 conditions,] and standard terms and conditions that the corporation has
29 established for the network participating [mail order or other non-re-
30 tail pharmacy] pharmacies. In such case, the contract shall not impose
31 any fee, co-payment, co-insurance, deductible or other condition,
32 including requiring monthly refills of a prescription that was written
33 for and may be filled for more than a thirty-day supply, on any covered
34 person who does not elect to purchase prescription fertility drugs
35 through a network participating mail order or other non-retail pharmacy;
36 provided, however, that the provisions of this section shall not super-
37 sede the terms of a collective bargaining agreement or apply to a
38 contract that is the result of a collective bargaining agreement between
39 an employer and a recognized or certified employee organization.
40 (3) Any policy that provides coverage for prescription fertility drugs
41 shall, in addition to the standard terms and conditions, require mail
42 order pharmacies to replace dispensed prescription fertility drugs for
43 which the mail or carrier service has proof of delivery that have been
44 not received by the insured, or are spoiled or damaged, provided that in
45 the case of a prescription fertility drug that has not been received by
46 the insured, the policy may require that the insured provide proof of
47 theft in the form of a filed police report reporting the theft and in
48 the case of a damaged or spoiled prescription fertility drug, the policy
49 may require that the damaged prescription fertility drug be returned to
50 the mail order pharmacy with the cost to be borne by such pharmacy, and
51 provided further that such unreceived, spoiled or damaged prescription
52 fertility drug shall be replaced before receipt of the police report or
53 the spoiled or damaged prescription fertility drug, as the case may be.
54 If such required police report is not provided or the damaged or spoiled
55 prescription fertility drug is not returned, the policy may require the
56 insured to reimburse the policy for the cost of the prescription fertil-
A. 10293 9
1 ity drug and, notwithstanding the forgoing, when an insured who was
2 previously required to reimburse the plan for a dispensed prescription
3 fertility drug that was not received by the insured, or was damaged or
4 spoiled, the policy may refuse to replace such prescription fertility
5 drug for such insured until such insured has provided the plan with the
6 required police report or returned the spoiled or damaged prescription
7 fertility drug. Replacement of a prescription fertility drug pursuant to
8 this paragraph shall not be limited to a specific number of occurrences
9 during a contract year.
10 § 5. Subsection (kk) of section 4303 of the insurance law, as amended
11 by chapter 11 of the laws of 2012 and as relettered by section 55 of
12 part D of chapter 56 of the laws of 2013, is amended to read as follows:
13 (kk) (1) Definitions. For the purpose of this subsection:
14 (A) "Same reimbursement amount" shall mean that any coverage described
15 under paragraph two of this subsection shall provide the same benchmark
16 index, including the same average wholesale price, maximum allowable
17 cost and national prescription drug codes to reimburse all pharmacies
18 participating in the insurance network regardless of whether a pharmacy
19 is a mail order pharmacy or a non-mail order pharmacy.
20 (B) "Mail order pharmacy" shall mean a pharmacy whose primary business
21 is to receive prescriptions by mail, telefax or through electronic
22 submissions and to dispense medication to patients through the use of
23 the United States mail or other common or contract carrier services and
24 provides any consultation with patients electronically rather than face-
25 to-face.
26 (C) "Standard terms and conditions" shall mean the contractual terms
27 and conditions applicable to all network participating pharmacies that
28 were in effect on June first, two thousand fifteen; provided that if an
29 insurer has established different standard terms and conditions for mail
30 order pharmacies and non-mail order retail pharmacies, the term standard
31 terms and conditions shall mean the standard terms and conditions that
32 were in effect on June first, two thousand fifteen for non-mail order
33 retail pharmacies, and provided further that any such standard terms and
34 conditions that require:
35 (i) Consultation with a pharmacist shall not require such consultation
36 be available at non-mail order pharmacies outside of such pharmacy's
37 regular hours of operation and shall require mail order pharmacies to
38 provide such consultation twenty-four hours a day, seven days a week;
39 (ii) Specific storage size for prescription drugs requiring special
40 handling, such as refrigeration, shall be based on the contracting phar-
41 macy's dispensing experience and shall not require a pharmacy to
42 increase its storage space when it has not been established that such
43 pharmacy's prescription volume requires such increased storage; and
44 (iii) Specific storage space for prescription drugs that do not
45 require special handling shall be based on the contracting pharmacy's
46 physical size and dispensing experience and shall not require a pharmacy
47 to increase its storage space when it has not been established that such
48 pharmacy's prescription volume requires such increased storage.
49 (2) Any contract issued by a medical expense indemnity corporation, a
50 hospital service corporation or a health services corporation that
51 provides coverage for prescription drugs shall permit each covered
52 person to fill any covered prescription that may be obtained at a
53 network participating mail order or other non-retail pharmacy, at the
54 covered person's option, at a network participating non-mail order
55 retail pharmacy provided that the network participating non-mail order
56 retail pharmacy agrees [in advance, through a contractual network agree-
A. 10293 10
1 ment,] to the same reimbursement amount[, as well as the same applicable
2 terms and conditions,] and standard terms and conditions that the corpo-
3 ration has established for the network participating [mail order or
4 other non-retail pharmacy] pharmacies. In such a case, the contract
5 shall not impose a copayment fee or other condition, including requiring
6 monthly refills of a prescription that was written for and may be filled
7 for more than a thirty-day supply, on any covered person who elects to
8 purchase drugs from a network participating non-mail order retail phar-
9 macy which is not also imposed on covered persons electing to purchase
10 drugs from a network participating mail order or other non-retail phar-
11 macy; provided, however, that the provisions of this section shall not
12 supersede the terms of a collective bargaining agreement or apply to a
13 contract that is the result of a collective bargaining agreement between
14 an employer and a recognized or certified employee organization.
15 (3) Any policy that provides coverage for prescription drugs shall, in
16 addition to the standard terms and conditions, require mail order phar-
17 macies to replace dispensed prescription drugs for which the mail or
18 carrier service has proof of delivery that have not been received by the
19 insured, or are spoiled or damaged, provided that in the case of a
20 prescription drug that has not been received by the insured, the policy
21 may require that the insured provide proof of theft in the form of a
22 filed police report reporting theft and in the case of a damaged or
23 spoiled prescription drug, the policy may require that the damaged
24 prescription drug be returned to the mail order pharmacy with the cost
25 to be borne by such pharmacy, and provided further that such unreceived,
26 spoiled or damaged prescription drug shall be replaced before receipt of
27 the police report or the spoiled or damaged prescription drug, as the
28 case may be. If such required police report is not provided or the
29 damaged or spoiled prescription drug is not returned, the policy may
30 require the insured to reimburse the policy for the cost of the
31 prescription drug and, notwithstanding the forgoing, when an insured who
32 was previously required to reimburse the plan for a dispensed
33 prescription drug that was not received by the insured, or was damaged
34 or spoiled, the policy may refuse to replace such prescription drug for
35 such insured until such insured has provided the plan with the required
36 police report or returned the spoiled or damaged prescription drug.
37 Replacement of a prescription drug pursuant to this paragraph shall not
38 be limited to a specific number of occurrences during a contract year.
39 § 6. Severability. If any clause, sentence, paragraph, section or part
40 of this act shall be adjudged by any court of competent jurisdiction to
41 be invalid, the judgement shall not affect, impair, or invalidate the
42 remainder thereof, but shall be confined in its operation to the clause,
43 sentence, paragraph, section or part thereof directly involved in the
44 controversy in which the judgement shall have been rendered.
45 § 7. This act shall take effect immediately.
