Bill Text: NY A00676 | 2015-2016 | General Assembly | Amended

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Bill Title: Relates to establishing a pharmacy benefit manager contract appeals process.

Spectrum: Slight Partisan Bill (Democrat 28-12)

Status: (Introduced - Dead) 2015-06-10 - substituted by s3346b [A00676 Detail]

Download: New_York-2015-A00676-Amended.html

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                           S T A T E   O F   N E W   Y O R K
       ________________________________________________________________________
                                        676--C
                              2015-2016 Regular Sessions
                                 I N  A S S E M B L Y
                                    January 7, 2015
                                      ___________
       Introduced  by  M.  of  A.  ROSENTHAL,  SIMANOWITZ,  BRINDISI,  SKOUFIS,
         CYMBROWITZ,  McDONALD,  LUPARDO,  CUSICK,  JAFFEE,  PAULIN,  DINOWITZ,
         QUART,  BROOK-KRASNY,  WEPRIN,  TITONE, DAVILA, RUSSELL, CROUCH, GOTT-
         FRIED, BENEDETTO, FAHY, TENNEY,  ABINANTI,  WALTER,  LAVINE,  GUNTHER,
         McDONOUGH  --  Multi-Sponsored  by -- M.  of A. CLARK, CURRAN, FITZPA-
         TRICK, HEVESI, LUPINACCI, MONTESANO,  PALMESANO,  RA,  RAIA,  SCHIMEL,
         SIMON  -- read once and referred to the Committee on Health -- commit-
         tee discharged, bill amended, ordered reprinted as amended and  recom-
         mitted  to  said  committee -- again reported from said committee with
         amendments, ordered reprinted  as  amended  and  recommitted  to  said
         committee  -- reported and referred to the Committee on Ways and Means
         -- committee discharged, bill amended, ordered  reprinted  as  amended
         and recommitted to said committee
       AN  ACT  to amend the public health law, in relation to pharmacy benefit
         managers
         THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
       BLY, DO ENACT AS FOLLOWS:
    1    Section  1.  The  public health law is amended by adding a new section
    2  280-a to read as follows:
    3    S 280-A. PHARMACY BENEFIT MANAGERS. 1. DEFINITIONS. AS  USED  IN  THIS
    4  SECTION, THE FOLLOWING TERMS SHALL HAVE THE FOLLOWING MEANINGS:
    5    (A)  "PHARMACY  BENEFIT  MANAGER"  MEANS AN ENTITY THAT CONTRACTS WITH
    6  PHARMACIES OR PHARMACY CONTRACTING AGENTS ON BEHALF OF  A  HEALTH  PLAN,
    7  STATE  AGENCY,  INSURER, MANAGED CARE ORGANIZATION, OR OTHER THIRD PARTY
    8  PAYOR TO PROVIDE PHARMACY HEALTH BENEFIT SERVICES OR ADMINISTRATION.
    9    (B) "MAXIMUM ALLOWABLE  COST  PRICE"  MEANS  A  MAXIMUM  REIMBURSEMENT
   10  AMOUNT  SET  BY  THE PHARMACY BENEFIT MANAGER FOR THERAPEUTICALLY EQUIV-
   11  ALENT MULTIPLE SOURCE GENERIC DRUGS.
   12    2. A PHARMACY BENEFIT MANAGER SHALL, WITH RESPECT TO CONTRACTS BETWEEN
   13  A PHARMACY BENEFIT MANAGER AND A PHARMACY OR, ALTERNATIVELY, A  PHARMACY
   14  BENEFIT  MANAGER  AND A PHARMACY'S CONTRACTING AGENT, SUCH AS A PHARMACY
        EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                             [ ] is old law to be omitted.
                                                                  LBD04032-09-5
       A. 676--C                           2
    1  SERVICES ADMINISTRATIVE ORGANIZATION, INCLUDE A  REASONABLE  PROCESS  TO
    2  APPEAL,  INVESTIGATE AND RESOLVE DISPUTES REGARDING MULTI-SOURCE GENERIC
    3  DRUG  PRICING.  THE  APPEALS  PROCESS  SHALL   INCLUDE   THE   FOLLOWING
    4  PROVISIONS:
    5    (A)  THE  RIGHT  TO  APPEAL  BY  THE  PHARMACY  AND/OR  THE PHARMACY'S
    6  CONTRACTING AGENT SHALL BE LIMITED TO THIRTY DAYS FOLLOWING THE  INITIAL
    7  CLAIM SUBMITTED FOR PAYMENT;
    8    (B)  A  TELEPHONE  NUMBER THROUGH WHICH A NETWORK PHARMACY MAY CONTACT
    9  THE PHARMACY BENEFIT MANAGER FOR THE PURPOSE OF FILING AN APPEAL AND  AN
   10  ELECTRONIC  MAIL  ADDRESS OF THE INDIVIDUAL WHO IS RESPONSIBLE FOR PROC-
   11  ESSING APPEALS;
   12    (C) THE PHARMACY BENEFIT MANAGER SHALL SEND AN ELECTRONIC MAIL MESSAGE
   13  ACKNOWLEDGING RECEIPT OF THE APPEAL. THE PHARMACY BENEFIT MANAGER  SHALL
   14  RESPOND  IN  AN ELECTRONIC MESSAGE TO THE PHARMACY AND/OR THE PHARMACY'S
   15  CONTRACTING AGENT FILING THE APPEAL WITHIN SEVEN BUSINESS DAYS  INDICAT-
   16  ING  ITS  DETERMINATION.  IF  THE  APPEAL IS DETERMINED TO BE VALID, THE
   17  MAXIMUM ALLOWABLE COST FOR THE DRUG SHALL BE ADJUSTED FOR THE  APPEALING
   18  PHARMACY EFFECTIVE AS OF THE DATE OF THE ORIGINAL CLAIM FOR PAYMENT. THE
   19  PHARMACY BENEFIT MANAGER SHALL REQUIRE THE APPEALING PHARMACY TO REVERSE
   20  AND  REBILL  THE  CLAIM  IN  QUESTION  IN  ORDER TO OBTAIN THE CORRECTED
   21  REIMBURSEMENT;
   22    (D) IF AN UPDATE TO THE MAXIMUM ALLOWABLE COST IS WARRANTED, THE PHAR-
   23  MACY BENEFIT MANAGER OR COVERED ENTITY SHALL ADJUST THE  MAXIMUM  ALLOW-
   24  ABLE COST OF THE DRUG EFFECTIVE FOR ALL SIMILARLY SITUATED PHARMACIES IN
   25  ITS  NETWORK  IN  THE  STATE ON THE DATE THE APPEAL WAS DETERMINED TO BE
   26  VALID; AND
   27    (E) IF AN APPEAL IS DENIED, THE PHARMACY BENEFIT MANAGER SHALL IDENTI-
   28  FY THE NATIONAL DRUG CODE  OF  A  THERAPEUTICALLY  EQUIVALENT  DRUG,  AS
   29  DETERMINED  BY  THE FEDERAL FOOD AND DRUG ADMINISTRATION, THAT IS AVAIL-
   30  ABLE FOR PURCHASE BY PHARMACIES IN THIS STATE  FROM  WHOLESALERS  REGIS-
   31  TERED  PURSUANT TO SUBDIVISION FOUR OF SECTION SIXTY-EIGHT HUNDRED EIGHT
   32  OF THE EDUCATION LAW AT A PRICE WHICH IS EQUAL TO OR LESS THAN THE MAXI-
   33  MUM ALLOWABLE COST FOR THAT DRUG AS DETERMINED BY THE  PHARMACY  BENEFIT
   34  MANAGER.
   35    S  2.  This  act shall take effect on the ninetieth day after it shall
   36  become a law and shall apply to any contract between a pharmacy and/or a
   37  pharmacy's contracting agent and a pharmacy benefit manager.