•  Summary 
  •  Actions 
  •  Committee Votes 
  •  Floor Votes 
  •  Memo 
  •  Text 
  •  LFIN 
  •  Chamber Video/Transcript 

A05411 Summary:

COSPNSRThiele, Englebright, Burdick, Montesano, Schmitt, Reilly, Lawler, McDonough, Barron, Lemondes, Dickens, Sillitti, Cusick, Simon, Angelino, Salka, Durso, Jackson, Gunther, Gottfried, Steck, Hawley, Forrest, Conrad
Add §341-a, Ins L
Requires health plans operating in the state to furnish the cost, benefit, and coverage data as required to the enrollee, his or her health care provider, or the third-party of his or her choosing.
Go to top

A05411 Text:

                STATE OF NEW YORK
                                                                Cal. No. 594
                               2021-2022 Regular Sessions
                   IN ASSEMBLY
                                    February 16, 2021
          STECK, HAWLEY, FORREST, CONRAD  --  read  once  and  referred  to  the
          Committee  on Insurance -- committee discharged, bill amended, ordered
          reprinted as amended and recommitted to said committee --  recommitted
          to the Committee on Insurance in accordance with Assembly Rule 3, sec.
          2  -- committee discharged, bill amended, ordered reprinted as amended
          and recommitted to said committee -- reported from committee, advanced
          to a third reading, amended and ordered reprinted, retaining its place
          on the order of third reading  --  again  amended  on  third  reading,
          ordered reprinted, retaining its place on the order of third reading
        AN  ACT to amend the insurance law, in relation to enacting the "patient
          Rx information and choice expansion act"
          The People of the State of New York, represented in Senate and  Assem-
        bly, do enact as follows:

     1    Section 1. This act shall be known and may be cited as the "patient Rx
     2  information and choice expansion act" or the "PRICE act".
     3    §  2.  The  insurance  law is amended by adding a new section 341-a to
     4  read as follows:
     5    § 341-a. Patient prescription pricing transparency. 1.    Definitions.
     6  As used in this section:
     7    (a) The terms "covered individual", "health plan", and "pharmacy bene-
     8  fit  manager"  shall  have  the  same meanings as defined by section two
     9  hundred eighty-a  of  the  public  health  law.  The  superintendent  is
    10  expressly authorized to interpret these terms as if the definitions were
    11  stated within this article.
    12    (b)  "Cost-sharing  information" means the amount a covered individual
    13  is required to pay to receive a drug that is covered under  the  covered
    14  individual's health plan.
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.

        A. 5411--D                          2
     1    (c)  "Covered/coverage"  means  those  health care services to which a
     2  covered individual is entitled under the terms of the health plan.
     3    (d)  "Interoperability  element"  means hardware, software, integrated
     4  technologies or related  licenses,  technical  information,  privileges,
     5  rights,  intellectual property, upgrades, or services that may be neces-
     6  sary to provide the data required in the requested format and consistent
     7  with the required format.
     8    (e) "Electronic health record" means a digital version of a  patient's
     9  paper  chart  and  medical  history  that  makes  information  available
    10  instantly and securely to authorized users.
    11    (f) "Electronic prescribing system" means a system that enables  pres-
    12  cribers  to  enter prescription information into a computer prescription
    13  device and securely transmit the  prescription  to  pharmacies  using  a
    14  special software program and connectivity to a transmission network.
    15    (g)  "Electronic  prescription"  means  an  electronic prescription as
    16  defined in section thirty-three hundred two of the public health law.
    17    (h) "Prescriber" means a health care provider  licensed  to  prescribe
    18  medication or medical devices in the state.
    19    (i)   "Real-time   benefit   tool"   or  "RTBT"  means  an  electronic
    20  prescription decision support tool that: (i) is capable  of  integrating
    21  with  prescribers'  electronic  prescribing and, if feasible, electronic
    22  health record systems; and (ii) complies with  the  technical  standards
    23  adopted  by  an  American National Standards Institute (ANSI) accredited
    24  standards development organization.
    25    (j) "Authorized  third-party"  shall  include  a  third-party  legally
    26  authorized  under  state  or  federal  law subject to a Health Insurance
    27  Portability and Accountability Act (HIPAA) business associate agreement.
    28    2. No later than July first, two thousand  twenty-three,  each  health
    29  plan  operating in the state shall, upon request of the covered individ-
    30  ual, his or her health care provider, or an  authorized  third-party  on
    31  their  behalf, furnish the cost, benefit, and coverage data set forth as
    32  required to the covered individual, his or her health care provider,  or
    33  the  third-party  of his or her choosing and shall ensure that such data
    34  is (i) current no later than one business day after any change is  made;
    35  (ii)  provided in real time; and (iii) in a format that is easily acces-
    36  sible to the covered individual, in the case of his or her  health  care
    37  provider, through an electronic health records system.
    38    3.  The  format  of the request shall use established industry content
    39  and transport standards published by:
    40    (a) A standards developing organization  accredited  by  the  American
    41  National Standards Institute (ANSI), including, the National Council for
    42  Prescription Drug Programs (NCPDP), ASC X12, Health Level 7; or
    43    (b)  A  relevant federal or state governing body, including the Center
    44  for Medicare & Medicaid Services or the Office of the National Coordina-
    45  tor for Health Information Technology; or
    46    (c) Another format deemed acceptable to the department which  provides
    47  the  data  prescribed in subdivision two of this section and in the same
    48  timeliness as required by this section.
    49    4. A facsimile shall not be considered an acceptable electronic format
    50  pursuant to this section.
    51    5. Upon such request, the following data shall  be  provided  for  any
    52  drug covered under the covered individual's health plan:
    53    (a) patient-specific eligibility information;
    54    (b)  patient-specific  prescription  cost  and  benefit  data, such as
    55  applicable formulary, benefit, coverage and cost-sharing  data  for  the

        A. 5411--D                          3
     1  prescribed  drug and clinically-appropriate alternatives, when appropri-
     2  ate;
     3    (c)  patient-specific cost-sharing information that describes variance
     4  in cost-sharing based on the pharmacy dispensing the prescribed drug  or
     5  its  alternatives, and in relation to the patient's benefit (i.e., spend
     6  related to out-of-pocket maximum);
     7    (d) information regarding lower cost clinically-appropriate  treatment
     8  alternatives; and
     9    (e) applicable utilization management requirements.
    10    6.  Any health plan or pharmacy benefit manager shall furnish the data
    11  as required whether the request is made using the drug's unique  billing
    12  code, such as a National Drug Code or Healthcare Common Procedure Coding
    13  System  code  or  descriptive  term.  A  health plan or pharmacy benefit
    14  manager shall not deny or unreasonably delay a request as  a  method  of
    15  blocking  the  data set forth as required from being shared based on how
    16  the drug was requested.
    17    7. A health plan or  pharmacy  benefit  manager  shall  not  restrict,
    18  prohibit,  or  otherwise  hinder    the prescriber from communicating or
    19  sharing benefit and coverage information that  reflects  other  choices,
    20  such  as  cash  price,  lower  cost clinically-appropriate alternatives,
    21  whether or not they are covered under  the  covered  individual's  plan,
    22  patient  assistance  and  support programs and the cost available at the
    23  patient's pharmacy of choice.
    24    8. A health plan or pharmacy benefit manager shall not, except as  may
    25  be  required  by  law, interfere with, prevent, or materially discourage
    26  access, exchange, or use of the data  as  required,  which  may  include
    27  charging fees, or not responding to a request for such data in a reason-
    28  able time frame; nor penalize a health care provider or professional for
    29  disclosing such information to a covered individual or legally prescrib-
    30  ing,  administering,  or ordering a clinically appropriate or lower-cost
    31  alternative.
    32    9. Nothing in this section shall be construed to limit access  to  the
    33  most   up-to-date   patient-specific   eligibility  or  patient-specific
    34  prescription cost and benefit data by the health plan.
    35    10. Nothing in this section shall interfere with patient choice and  a
    36  health   care  professional's  ability  to  convey  the  full  range  of
    37  prescription drug cost options to a patient.  Health plans  or  pharmacy
    38  benefit  managers  shall  not  restrict  a health care professional from
    39  communicating to the patient prescription cost options.
    40    11. No RTBT shall require a patient to utilize specific plan preferred
    41  drugs or pharmacies.
    42    § 3.  Severability. If any provision of this act, or  any  application
    43  of  any  provision of this  act, is held to be invalid, or to violate or
    44  be inconsistent with any   federal law or  regulation,  that  shall  not
    45  affect  the  validity  or   effectiveness of any other provision of this
    46  act, or of any other  application of any provision of  this  act,  which
    47  can  be given effect  without that provision or application; and to that
    48  end, the provisions  and applications of this act are severable.
    49    § 4. This act shall take effect one hundred eighty days after it shall
    50  have become a law. Effective immediately, the addition, amendment and/or
    51  repeal of any rule or regulation necessary  for  the  implementation  of
    52  this  act  on its effective date are authorized to be made and completed
    53  on or before such effective date.
Go to top