Bill Text: NY A00901 | 2023-2024 | General Assembly | Introduced

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Requires a utilization review agent to follow certain rules when establishing a step therapy protocol; requires that the protocol accepts any attestation submitted by the insured's health care professional stating that a required drug has failed as prima facie evidence that the required drug has failed.

Spectrum: Moderate Partisan Bill (Democrat 27-6)

Status: (Introduced) 2024-06-03 - substituted by s1267a [A00901 Detail]

Download: New_York-2023-A00901-Introduced.html

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                STATE OF NEW YORK
        ________________________________________________________________________

                                           901

                               2023-2024 Regular Sessions

                   IN ASSEMBLY

                                    January 11, 2023
                                       ___________

        Introduced  by M. of A. McDONALD, STECK -- read once and referred to the
          Committee on Insurance

        AN ACT to amend the insurance law and the public health law, in relation
          to requiring a utilization review agent to follow certain  rules  when
          establishing a step therapy protocol

          The  People of the State of New York, represented in Senate and Assem-
        bly, do enact as follows:

     1    Section 1. Subsection (a) of section 4902  of  the  insurance  law  is
     2  amended by adding two new paragraphs 14 and 15 to read as follows:
     3    (14)  When  establishing a step therapy protocol, a utilization review
     4  agent shall ensure that the protocol cannot:
     5    (i) require a prescription drug that has  not  been  approved  by  the
     6  United  States  Food  and  Drug Administration for the medical condition
     7  being treated;
     8    (ii) require an insured to try and fail on more than one  drug  before
     9  providing coverage to the insured for the prescribed drug;
    10    (iii)  require the use of a step therapy-required drug for longer than
    11  thirty days;
    12    (iv) be imposed on an insured if the insured has taken the  prescribed
    13  drug covered by the plan within the past three hundred sixty-five days;
    14    (v)  require  a  newly  enrolled  insured to repeat step therapy for a
    15  prescribed drug where that insured already completed  step  therapy  for
    16  that drug under a prior plan; and
    17    (vi) be imposed on an insured for a prescribed drug that was previous-
    18  ly  approved  for  coverage  by  a plan for a specific medical condition
    19  after the insured's plan implements a formulary change that impacts  the
    20  formulary status of the prescribed drug.
    21    (15)  When  establishing a step therapy protocol, a utilization review
    22  agent shall ensure that the protocol accepts any  attestation  submitted
    23  by  the  insured's  health  care professional as defined in section four

         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD02501-01-3
        A. 901                              2

     1  thousand nine hundred of this title stating that  a  required  drug  has
     2  failed as prima facie evidence that the required drug has failed.
     3    §  2.  Subsections (c-3) and (g) of section 4903 of the insurance law,
     4  subsection (c-3) as added and subsection (g) as amended by  chapter  512
     5  of the laws of 2016, are amended to read as follows:
     6    (c-3)  Upon  a  determination that the step therapy protocol should be
     7  overridden, the health plan shall authorize immediate coverage  for  the
     8  prescription  drug  prescribed  by  the  insured's  treating health care
     9  professional. Any approval of a step therapy protocol override  determi-
    10  nation request shall be honored until the later of twelve months follow-
    11  ing the date of the approval or renewal of the plan.
    12    (g)  Failure  by  the utilization review agent to make a determination
    13  within the time periods prescribed in this section shall be deemed to be
    14  an adverse determination subject to  appeal  pursuant  to  section  four
    15  thousand  nine hundred four of this title, provided, however, that fail-
    16  ure to meet such time periods for a step therapy protocol as defined  in
    17  subsection  (g-9)  of section forty-nine hundred of this title or a step
    18  therapy protocol override determination pursuant to  subsections  (c-1),
    19  (c-2) and (c-3) of this section shall be deemed to be an override of the
    20  step  therapy  protocol.  A utilization review agent's failure to comply
    21  with  any  of  the  step  therapy  protocol  requirements  required   in
    22  subsections  fourteen  and fifteen of section four thousand nine hundred
    23  two of this title shall be considered a basis for granting  an  override
    24  of the step therapy protocol.
    25    §  3.  Section  4902 of the public health law is amended by adding two
    26  new subdivisions 5 and 6 to read as follows:
    27    5. When establishing a step therapy  protocol,  a  utilization  review
    28  agent shall ensure that the protocol cannot:
    29    (a)  require  a  prescription  drug  that has not been approved by the
    30  United States Food and Drug Administration  for  the  medical  condition
    31  being treated;
    32    (b)  require  an enrollee to try and fail on more than one drug before
    33  providing coverage to the insured for the prescribed drug;
    34    (c) require the use of a step therapy-required drug  for  longer  than
    35  thirty days;
    36    (d) be imposed on an enrollee if the enrollee has taken the prescribed
    37  drug covered by the plan within the past three hundred sixty-five days;
    38    (f)  require  a  newly  enrolled enrollee to repeat step therapy for a
    39  prescribed drug where that enrollee already completed step  therapy  for
    40  that drug under a prior plan; and
    41    (g) be imposed on an enrollee for a prescribed drug that was previous-
    42  ly  approved  for  coverage  by  a plan for a specific medical condition
    43  after the enrollee's plan implements a formulary change that impacts the
    44  formulary status of the prescribed drug.
    45    6. When establishing a step therapy  protocol,  a  utilization  review
    46  agent  shall  ensure that the protocol accepts any attestation submitted
    47  by the enrollee's health care professional as defined in section  forty-
    48  nine  hundred  of  this title stating that a required drug has failed as
    49  prima facie evidence that the required drug has failed.
    50    § 4. Subdivisions 3-c and 7 of section 4903 of the public health  law,
    51  subdivision  3-c as added and subdivision 7 as amended by chapter 512 of
    52  the laws of 2016, are amended to read as follows:
    53    3-c. Upon a determination that the step  therapy  protocol  should  be
    54  overridden,  the  health plan shall authorize immediate coverage for the
    55  prescription drug or drugs prescribed by the enrollee's treating  health
    56  care  professional.  Any  approval  of  a step therapy protocol override
        A. 901                              3

     1  determination request shall be honored until the later of twelve  months
     2  following the date of the approval or renewal of the plan.
     3    7.  Failure  by  the  utilization review agent to make a determination
     4  within the time periods prescribed in this section shall be deemed to be
     5  an adverse determination subject to appeal pursuant  to  section  forty-
     6  nine hundred four of this title, provided, however, that failure to meet
     7  such  time periods for a step therapy protocol as defined in subdivision
     8  seven-f-three of section forty-nine hundred of  this  title  or  a  step
     9  therapy   protocol   override  determination  pursuant  to  subdivisions
    10  three-a, three-b and three-c of this section shall be deemed  to  be  an
    11  override  of  the  step therapy protocol.   A utilization review agent's
    12  failure to comply with any of the  step  therapy  protocol  requirements
    13  required  in subdivisions five and six of section forty-nine hundred two
    14  of this title shall be considered a basis for granting  an  override  of
    15  the step therapy protocol.
    16    § 5. This act shall take effect immediately.