Bill Text: NY A05046 | 2021-2022 | General Assembly | Introduced
Bill Title: Relates to access to appropriate drugs at reasonable prices, formulary exceptions, standing prior authorizations and external appeals; to access to retail pharmacies, prescription synchronization, limits on patient drug costs, explanations of benefits and rebates; to prescription drug synchronization; to pharmacy benefit management; and to limits on copayments and drug substitutions.
Spectrum: Strong Partisan Bill (Democrat 12-1)
Status: (Introduced - Dead) 2022-01-05 - referred to insurance [A05046 Detail]
Download: New_York-2021-A05046-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 5046 2021-2022 Regular Sessions IN ASSEMBLY February 10, 2021 ___________ Introduced by M. of A. SOLAGES, TAYLOR, SEAWRIGHT, MONTESANO, RAMOS, SIMON, L. ROSENTHAL, GOTTFRIED, GLICK, BARRON, DICKENS, GUNTHER -- Multi-Sponsored by -- M. of A. COOK -- read once and referred to the Committee on Insurance AN ACT to amend the insurance law and the public health law, in relation to access to appropriate drugs at reasonable prices, formulary exceptions, standing prior authorizations and external appeals; to amend the insurance law, in relation to access to retail pharmacies, prescription synchronization, limits on patient drug costs, explana- tions of benefits and rebates; to amend the social services law, in relation to prescription drug synchronization; and to amend the educa- tion law, in relation to limits on copayments and drug substitutions The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. The insurance law is amended by adding a new section 4806 2 to read as follows: 3 § 4806. Access to appropriate drugs at reasonable prices; formulary 4 exceptions; standing prior authorization requirement. (a) An insurer 5 offering a prescription drug benefit with a formulary of approved or 6 preferred drugs shall establish a procedure by which it determines 7 whether a formulary drug provides appropriate therapeutic benefits to 8 meet the particular health care needs of an insured. If the insurer 9 determines that no formulary drug provides appropriate therapeutic bene- 10 fits to meet the particular health care needs of an insured, the insurer 11 shall cover the cost of an off-formulary drug for that insured, at no 12 additional cost to the insured beyond what the insured would otherwise 13 pay for a preferred brand name drug on the formulary. The determinations 14 whether a drug provides appropriate therapeutic benefits and whether a 15 non-formulary drug is necessary to meet the particular health care needs 16 of the insured are utilization review decisions and are reviewable in EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD06436-02-1A. 5046 2 1 accordance with article forty-nine of this chapter, including external 2 appeal. 3 (b) (1) For purposes of this section, "prior authorization require- 4 ment" means any practice implemented by an insurer in which coverage of 5 a prescription drug or device is dependent upon a covered person or a 6 health care practitioner obtaining approval from the insurer prior to 7 the service, device, or drug being performed, received, or prescribed, 8 as applicable. "Prior authorization" includes prospective or utilization 9 review procedures conducted prior to providing a drug or device. 10 (2) An insurer which requires prior authorizations for particular 11 prescription drugs shall have a procedure by which an insured who is 12 being prescribed such drug for a chronic condition may obtain a standing 13 prior authorization for a drug for the lesser of the following from the 14 date of the approval: (i) twelve months; or (ii) the last day of the 15 covered person's eligibility under the policy or plan. 16 (3) As a condition of such standing prior authorization, if according 17 to the available medical and scientific evidence the patient's chronic 18 condition is likely to change during the standing referral period, the 19 insurer or health plan may require the prescribing health care practi- 20 tioner to certify to the insurer, not more frequently than on a quarter- 21 ly basis, that the patient's chronic condition has not changed mate- 22 rially with respect to the need for the prescription. 23 (4) A twelve-month standing prior authorization provided under para- 24 graph two of this subsection does not apply to and is not required for 25 any of the following: 26 (i) medications that have a typical course of administration of less 27 than one year or for which available medical or scientific evidence does 28 not support a twelve-month period of use, in which case the standing 29 prior authorization period shall be the typical course of administration 30 or the period of use supported by the available medical or scientific 31 evidence; 32 (ii) medications that require an initial trial period to determine 33 effectiveness and tolerability, except that after such trial period a 34 one-year, or greater, prior authorization period will be given; and 35 (iii) medications that are schedule II controlled substance or a sche- 36 dule III controlled substance containing hydrocodone. 37 (5) For drugs used to treat acute conditions, insurers shall grant 38 standing prior authorizations for the period that the medical and scien- 39 tific evidence shows to be the anticipated period for the course of 40 treatment to have its intended effect. 41 (6) The standing prior authorizations provided for in this section are 42 no longer valid and automatically terminate if there are changes to 43 federal or state laws or federal regulatory guidance or compliance 44 information finding that the drug in question is no longer approved or 45 safe for the prescribed purpose. 46 (7) If an AB-rated generic drug that is therapeutically equivalent to 47 the drug subject to a standing prior authorization becomes available, 48 the insurer may substitute such newly released drug for the drug subject 49 to the standing prior authorization, provided advance notice is given to 50 the insured. 51 (8) The determination whether the drug is being prescribed to treat a 52 chronic condition and the period over which the course of treatment for 53 an acute condition is anticipated to have its intended effect are utili- 54 zation review decisions and are reviewable in accordance with article 55 forty-nine of this chapter, including external appeal.A. 5046 3 1 (c) (1) If a formulary drug being prescribed for an insured is removed 2 by the insurer from its formulary for reasons other than a determination 3 that the approval for the use of that drug has been withdrawn by the 4 U.S. Food and Drug Administration, the insurer shall continue to cover 5 that drug for that insured for a transitional period to the end of the 6 plan year at the same copayment as charged when the drug was on formu- 7 lary. Thereafter, the insured may seek continued coverage of the drug, 8 if appropriate, pursuant to the provisions of subsection (a) of this 9 section. 10 (2) If a formulary drug being prescribed for an insured is moved by 11 the insurer to a higher cost sharing tier in its formulary for reasons 12 other than release of an AB-rated generic drug, the insurer shall 13 continue to cover that drug for that insured for a transitional period 14 to the end of the plan year at the same copayment as charged when the 15 drug was on formulary. Thereafter, the insured may seek continued cover- 16 age of the drug, if appropriate, pursuant to the provisions of 17 subsection (a) of this section. 18 (3) If an insurer that provides prescription drug coverage enrolls a 19 new insured who is currently being prescribed a drug for a chronic 20 health condition, or as part of an ongoing course of treatment for an 21 acute condition, and that drug is not on the insurer's formulary, the 22 insurer shall cover that drug for that insured at no additional cost to 23 the insured beyond what the insured would otherwise pay for a preferred 24 brand name drug on the formulary, for a transitional period of ninety 25 (90) days from the effective date of enrollment. The insured must adhere 26 to the insurer's quality assurance requirements and provide to the 27 insurer necessary medical information related to the prescription and 28 otherwise adhere to the insurer's policies and procedures including, but 29 not limited to procedures regarding obtaining pre-authorization and a 30 treatment plan approved by the insurer. In no event shall this 31 subsection be construed to require an insurer to provide coverage for 32 benefits not otherwise covered. The transitional period does not 33 preclude the insured from seeking continued coverage of the drug, if 34 appropriate, pursuant to the provisions of subsection (a) of this 35 section. 36 § 2. The public health law is amended by adding a new section 4406-h 37 to read as follows: 38 § 4406-h. Access to appropriate drugs at reasonable prices; formulary 39 exceptions; standing prior authorization requirement. 1. A health main- 40 tenance organization offering a prescription drug benefit with a formu- 41 lary of approved or preferred drugs shall have a procedure by which it 42 determines whether a formulary drug provides appropriate therapeutic 43 benefits to meet the particular health care needs of an enrollee. If the 44 health maintenance organization determines that no formulary drug 45 provides appropriate therapeutic benefits to meet the particular health 46 care needs of an enrollee, the health maintenance organization shall 47 cover the cost of an off-formulary drug for that enrollee, at no addi- 48 tional cost to the enrollee beyond what the enrollee would otherwise pay 49 for a preferred brand name drug on the formulary. The determinations 50 whether a drug provides appropriate therapeutic benefits and whether a 51 non-formulary drug is necessary to meet the particular health care needs 52 of the insured are utilization review decisions and are reviewable in 53 accordance with article forty-nine of this chapter, including external 54 appeal. 55 2. (a) For purposes of this section, "prior authorization requirement" 56 means any practice implemented by a health maintenance organization inA. 5046 4 1 which coverage of a prescription drug or device is dependent upon a 2 covered person or a health care practitioner obtaining approval from the 3 health maintenance organization prior to the service, device, or drug 4 being performed, received, or prescribed, as applicable. "Prior authori- 5 zation" includes prospective or utilization review procedures conducted 6 prior to providing a drug or device. 7 (b) A health maintenance organization which requires prior authori- 8 zations for particular prescription drugs shall have a procedure by 9 which an enrollee who is being prescribed such drug for a chronic condi- 10 tion may obtain a standing prior authorization for a drug for the lesser 11 of the following from the date of the approval: (i) twelve months; (ii) 12 the last day of the enrollee's eligibility under the policy or plan. 13 (c) As a condition of such standing prior authorization, if according 14 to the available medical and scientific evidence the enrollee's chronic 15 condition is likely to change during the standing referral period, the 16 insurer or health plan may require the prescribing health care practi- 17 tioner to certify to the health maintenance organization, not more 18 frequently than on a quarterly basis, that the enrollee's chronic condi- 19 tion has not changed materially with respect to the need for the 20 prescription. 21 (d) A twelve-month standing prior authorization provided under subpar- 22 agraph (i) of paragraph (b) of this subdivision does not apply to and is 23 not required for any of the following: 24 (i) medications that have a typical course of administration of less 25 than one year or for which available medical or scientific evidence does 26 not support a twelve-month period of use, in which case the standing 27 prior authorization period shall be the typical course of administration 28 or the period of use supported by the available medical or scientific 29 evidence; 30 (ii) medications that require an initial trial period to determine 31 effectiveness and tolerability, except that after such trial period a 32 one-year, or greater, prior authorization period will be given; and 33 (iii) medications that are schedule II controlled substance or a sche- 34 dule III controlled substance containing hydrocodone. 35 (e) For drugs used to treat acute conditions, insurers shall grant 36 standing prior authorizations for the period that the medical and scien- 37 tific evidence shows to be the anticipated period for the course of 38 treatment to have its intended effect. 39 (f) The standing prior authorizations provided for in this section are 40 no longer valid and automatically terminate if there are changes to 41 federal or state laws or federal regulatory guidance or compliance 42 information finding that the drug in question is no longer approved or 43 safe for the prescribed purpose. 44 (g) If an AB-rated generic drug that is therapeutically equivalent to 45 the drug subject to a standing prior authorization becomes available, 46 the health maintenance organization may substitute such newly released 47 drug for the drug subject to the standing prior authorization, provided 48 advance notice is given to the enrollee. 49 (h) The determination whether the drug is being prescribed to treat a 50 chronic condition and the period over which the course of treatment for 51 an acute condition is anticipated to have its intended effect are utili- 52 zation review decisions and are reviewable in accordance with article 53 forty-nine of this chapter, including external appeal. 54 3. (a) If a formulary drug being prescribed for an enrollee is removed 55 by the health maintenance organization from its formulary for reasons 56 other than a determination that the approval for the use of that drugA. 5046 5 1 has been withdrawn by the U.S. Food and Drug Administration, the health 2 maintenance organization shall continue to cover that drug for that 3 enrollee for a transitional period to the end of the plan year at the 4 same copayment as charged when the drug was on formulary. Thereafter, 5 the enrollee may seek continued coverage of the drug, if appropriate, 6 pursuant to the provisions of subdivision one of this section. 7 (b) If a formulary drug being prescribed for an insured is moved by 8 the health maintenance organization to a higher cost sharing tier in its 9 formulary for reasons other than release of an AB-rated generic drug, 10 the health maintenance organization shall continue to cover that drug 11 for that enrollee for a transitional period to the end of the plan year 12 at the same copayment as charged when the drug was on formulary. There- 13 after, the enrollee may seek continued coverage of the drug, if appro- 14 priate, pursuant to the provisions of subdivision one of this section. 15 (c) If a health maintenance organization that provides prescription 16 drug coverage enrolls a new enrollee who is currently being prescribed a 17 drug for a chronic health condition, or as part of an ongoing course of 18 treatment for an acute condition, and that drug is not on the health 19 maintenance organization's formulary, the health maintenance organiza- 20 tion shall cover that drug for that enrollee at no additional cost to 21 the enrollee beyond what the enrollee would otherwise pay for a 22 preferred brand name drug on the formulary, for a transitional period of 23 ninety (90) days from the effective date of enrollment. The enrollee 24 must adhere to the health maintenance organization's quality assurance 25 requirements and provide to the health maintenance organization neces- 26 sary medical information related to the prescription and otherwise 27 adhere to the health maintenance organization's policies and procedures 28 including, but not limited to procedures regarding obtaining pre-author- 29 ization and a treatment plan approved by the health maintenance organ- 30 ization. In no event shall this subdivision be construed to require a 31 health maintenance organization to provide coverage for benefits not 32 otherwise covered. The transitional period does not preclude the enrol- 33 lee from seeking continued coverage of the drug, if appropriate, pursu- 34 ant to the provisions of subdivision one of this section. 35 § 3. Section 4903 of the insurance law is amended by adding a new 36 subsection (j) to read as follows: 37 (j) (1) Each health plan shall make available to all participating 38 health care providers on its web site or provider portal a listing of 39 its prior authorization requirements, including specific information or 40 documentation that a provider must submit in order for the prior author- 41 ization request to be considered complete. 42 (2) Each health plan shall make available on its web site information 43 about the policies, contracts, or agreements offered by it that clearly 44 identifies specific services, drugs, or devices to which a prior author- 45 ization requirement exists. 46 (3) Each health plan shall give thirty (30) days advance written 47 notice to participating providers of any changes in prior authorization 48 requirements. Each health plan shall also give thirty (30) days advance 49 written notice to plan participants of any changes in prior authori- 50 zation requirements with respect to any services, drugs or devices which 51 such participant is currently being prescribed or has been prescribed in 52 the preceding year. 53 § 4. Section 4903 of the public health law is amended by adding a new 54 subdivision 10 to read as follows: 55 10. (a) Each health plan shall make available to all participating 56 health care providers on its web site or provider portal a listing ofA. 5046 6 1 its prior authorization requirements, including specific information or 2 documentation that a provider must submit in order for the prior author- 3 ization request to be considered complete. 4 (b) Each health plan shall make available on its web site information 5 about the policies, contracts, or agreements offered by it that clearly 6 identifies specific services, drugs, or devices to which a prior author- 7 ization requirement exists. 8 (c) Each health plan shall give thirty (30) days advance written 9 notice to participating providers of any changes in prior authorization 10 requirements. Each health plan shall also give thirty (30) days advance 11 written notice to plan participants of any changes in prior authori- 12 zation requirements with respect to any services, drugs or devices which 13 such participant is currently being prescribed or has been prescribed in 14 the preceding year. 15 § 5. Subsection (b) of section 4910 of the insurance law is amended by 16 adding a new paragraph 5 to read as follows: 17 (5) (A) The insured has had a drug prescription denied on the ground 18 that it is not on the health care plan's formulary, and that the health 19 care plan has a covered drug on the formulary which is effective to meet 20 the particular health care needs of an insured; and 21 (B) The insured's attending physician, who shall be a licensed physi- 22 cian or other health care provider qualified to prescribe drugs to treat 23 the insured for the health service sought, certifies that available 24 formulary drugs are not sufficiently effective to meet the insured's 25 health needs, or are otherwise contraindicated for the insured, and 26 recommends an off-formulary drug that will be effective to treat the 27 insured. 28 § 6. Subdivision 2 of section 4910 of the public health law is amended 29 by adding a new paragraph (e) to read as follows: 30 (e) (i) The enrollee has had a drug prescription denied on the ground 31 that it is not on the health maintenance organization's formulary, and 32 that the health maintenance organization has a covered drug on the 33 formulary which is effective to meet the particular health care needs of 34 an enrollee; and 35 (ii) The enrollee's attending physician, who shall be a licensed 36 physician or other health care provider qualified to prescribe drugs to 37 treat the insured for the health service sought, certifies that avail- 38 able formulary drugs are not sufficiently effective to meet the 39 enrollee's health needs, or are otherwise contraindicated for the enrol- 40 lee, and recommends an off-formulary drug that will be effective to 41 treat the enrollee. 42 § 7. Paragraph 4 of subsection (b) of section 4914 of the insurance 43 law is amended by adding a new subparagraph (E) to read as as follows: 44 (E) For external appeals requested pursuant to paragraph five of 45 subsection (b) of section four thousand nine hundred ten of this title 46 relating to an off-formulary drug denial, the external appeal agent 47 shall review the utilization review agent's final adverse determination 48 and, in accordance with the provisions of this title, shall make a 49 determination as to whether the non-formulary drug shall be covered by 50 the health plan; provided that such determination shall: 51 (i) be conducted only by one or a greater odd number of clinical peer 52 reviewers; 53 (ii) be accompanied by a written statement: 54 (I) that the off-formulary drug prescription shall be covered by the 55 health care plan either when the reviewer or a majority of the panel of 56 reviewers determines, upon review of the available medical and scientif-A. 5046 7 1 ic evidence, the formulary drug deemed sufficient by the health plan 2 will not be as effective in addressing the insured's health problem for 3 which a drug has been prescribed as the off-formulary drug prescribed by 4 the treating physician or otherwise be appropriate to meet the partic- 5 ular health care needs of the insured, which is more likely to provide a 6 beneficial clinical outcome; or 7 (II) upholding the health plan's denial of coverage. 8 § 8. Paragraph (d) of subdivision 2 of section 4914 of the public 9 health law is amended by adding a new subparagraph (E) to read as 10 follows: 11 (E) For external appeals requested pursuant to paragraph (e) of subdi- 12 vision two of section forty-nine hundred ten of this title relating to 13 an off-formulary drug denial, the external appeal agent shall review the 14 utilization review agent's final adverse determination and, in accord- 15 ance with the provisions of this title, shall make a determination as to 16 whether the non-formulary drug shall be covered by the health mainte- 17 nance organization; provided that such determination shall: 18 (i) be conducted only by one or a greater odd number of clinical peer 19 reviewers; 20 (ii) be accompanied by a written statement: 21 (1) that the off-formulary drug prescription shall be covered by the 22 health maintenance organization either when the reviewer or a majority 23 of the panel of reviewers determines, upon review of the available 24 medical and scientific evidence, the formulary drug deemed sufficient by 25 the health maintenance organization will not be as effective in address- 26 ing the enrollee's health problem for which a drug has been prescribed 27 as the off-formulary drug prescribed by the treating physician or other- 28 wise be appropriate to meet the particular health care needs of the 29 enrollee, which is more likely to provide a beneficial clinical outcome; 30 or 31 (2) upholding the health maintenance organization's denial of cover- 32 age. 33 § 9. The opening paragraph of paragraph 28 of subsection (i) of 34 section 3216 of the insurance law, as added by chapter 589 of the laws 35 of 2011, is designated subparagraph (A) and a new subparagraph (B) is 36 added to read as follows: 37 (B) Notwithstanding any other provision of this paragraph, if a pres- 38 criber, after consulting with the insurer regarding the appropriateness 39 of mail order delivery given: (i) the residence or delivery location of 40 the insured; (ii) the medical condition of the insured; (iii) the stor- 41 age requirements of the drug; (iv) the availability of the insured to 42 receive the prescription; or (v) the insured's ability to comprehend 43 pharmaceutical guidance and support over the telephone, determines that 44 a drug as prescribed on an individual basis is most appropriately filled 45 at a retail location, provided that an in-network retail pharmacy of the 46 patient's choosing agrees to the same reimbursement amount and is able 47 to fill the prescription, the prescriber's determination shall be final. 48 § 10. The opening paragraph of paragraph 18 of subsection (1) of 49 section 3221 of the insurance law is designated subparagraph (A) and a 50 new subparagraph (B) is added to read as follows: 51 (B) Notwithstanding any other provision of this paragraph, if a pres- 52 criber, after consulting with the insurer regarding the appropriateness 53 of mail order delivery given: (i) the residence or delivery location of 54 the insured; (ii) the medical condition of the insured; (iii) the stor- 55 age requirements of the drug; (iv) the availability of the insured to 56 receive the prescription; or (v) the insured's ability to comprehendA. 5046 8 1 pharmaceutical guidance and support over the telephone, determines that 2 a drug as prescribed on an individual basis is most appropriately filled 3 at a retail location, provided that an in-network retail pharmacy of the 4 patient's choosing agrees to the same reimbursement amount and is able 5 to fill the prescription, the prescriber's determination shall be final. 6 § 11. The opening paragraph of subsection (kk) of section 4303 of the 7 insurance law is designated paragraph 1 and a new paragraph 2 is added 8 to read as follows: 9 (2) Notwithstanding any other provision of this subsection, if a pres- 10 criber, after consulting with the insurer regarding the appropriateness 11 of mail order delivery given: (A) the residence or delivery location of 12 the covered person; (B) the medical condition of the covered person; (C) 13 the storage requirements of the drug; (D) the availability of the 14 covered person to receive the prescription; or (E) the covered person's 15 ability to comprehend pharmaceutical guidance and support over the tele- 16 phone, determines that a drug as prescribed on an individual basis is 17 most appropriately filled at a retail location, provided that an in-net- 18 work retail pharmacy of the patient's choosing agrees to the same 19 reimbursement amount and is able to fill the prescription, the 20 prescriber's determination shall be final. 21 § 12. The insurance law is amended by adding a new section 3224-e to 22 read as follows: 23 § 3224-e. Prescription synchronization. (a) Every individual or group 24 health insurance policy providing prescription drug coverage when appli- 25 cable to permit synchronization shall permit and apply a daily prorated 26 cost-sharing rate to prescriptions that are dispensed by a network phar- 27 macy for less than a thirty day supply, when it is agreed among the 28 covered individual, a health care practitioner, and a pharmacist that 29 synchronization of multiple prescriptions for the treatment of a chronic 30 illness is in the best interest of the covered individual for the 31 management or treatment of that chronic illness provided that all of the 32 following apply: 33 (1) the medications are covered by the policy or plan; 34 (2) the medications are used for treatment and management of chronic 35 conditions that are subject to refills; 36 (3) the medications are not a schedule II controlled substance or a 37 schedule III controlled substance containing hydrocodone; 38 (4) the medications meet all prior authorization criteria specific to 39 medications at the time of the synchronization request; 40 (5) the medications are of a formulation that can be effectively split 41 over required short fill periods to achieve synchronization; and 42 (6) the medications do not have quantity limits or dose optimization 43 criteria or requirements that would be violated in fulfilling synchroni- 44 zation. 45 (b) No individual or group health insurance policy providing 46 prescription drug coverage shall deny coverage for the dispensing of a 47 medication for partial fill when it is for purposes of synchronizing the 48 patient's medications. When applicable to permit synchronization, every 49 individual or group health insurance policy must allow a pharmacy to 50 override any denial codes indicating that a prescription is being 51 refilled too soon for the purposes of medication synchronization. 52 (c) Dispensing fees for partially filled or refilled prescriptions 53 shall be paid in full for each prescription dispensed, regardless of any 54 pro-rated copay for the beneficiary or fee paid for alignment services.A. 5046 9 1 (d) Nothing in this section shall be deemed to require health care 2 practitioners and pharmacists to synchronize the refilling of multiple 3 prescriptions for a covered individual. 4 (e) The requirements of this section shall apply only once for each 5 prescription drug subject to medication synchronization except when 6 either of the following occurs: 7 (1) the prescriber changes the dosage or frequency of administration 8 of the prescription drug subject to a medication synchronization; or 9 (2) the prescriber prescribes a different drug. 10 § 13. The insurance law is amended by adding a new section 4303-b to 11 read as follows: 12 § 4303-b. Prescription synchronization. (a) Every hospital service 13 corporation and health service corporation providing prescription drug 14 coverage when applicable to permit synchronization shall permit and 15 apply a daily prorated cost-sharing rate to prescriptions that are 16 dispensed by a network pharmacy for less than a thirty day supply, when 17 it is agreed among the covered individual, a health care practitioner, 18 and a pharmacist that synchronization of multiple prescriptions for the 19 treatment of a chronic illness is in the best interest of the covered 20 individual for the management or treatment of that chronic illness 21 provided that all of the following apply: 22 (1) the medications are covered by the policy or plan; 23 (2) the medications are used for treatment and management of chronic 24 conditions that are subject to refills; 25 (3) the medications are not a schedule II controlled substance or a 26 schedule III controlled substance containing hydrocodone; 27 (4) the medications meet all prior authorization criteria specific to 28 medications at the time of the synchronization request; 29 (5) the medications are of a formulation that can be effectively split 30 over required short fill periods to achieve synchronization; and 31 (6) the medications do not have quantity limits or dose optimization 32 criteria or requirements that would be violated in fulfilling synchroni- 33 zation. 34 (b) No hospital service corporation or health service corporation 35 providing prescription drug coverage shall deny coverage for the 36 dispensing of a medication for partial fill when it is for purposes of 37 synchronizing the patient's medications. When applicable to permit 38 synchronization, every hospital service corporation or health service 39 corporation providing prescription drug coverage must allow a pharmacy 40 to override any denial codes indicating that a prescription is being 41 refilled too soon for the purposes of medication synchronization. 42 (c) Dispensing fees for partially filled or refilled prescriptions 43 shall be paid in full for each prescription dispensed, regardless of any 44 pro-rated copay for the beneficiary or fee paid for alignment services. 45 (d) Nothing in this section shall be deemed to require health care 46 practitioners and pharmacists to synchronize the refilling of multiple 47 prescriptions for a covered individual. 48 (e) The requirements of this section shall apply only once for each 49 prescription drug subject to medication synchronization except when 50 either of the following occurs: 51 (1) The prescriber changes the dosage or frequency of administration 52 of the prescription drug subject to a medication synchronization; or 53 (2) The prescriber prescribes a different drug. 54 § 14. Subdivision 9 of section 367-a of the social services law is 55 amended by adding a new paragraph (i) to read as follows:A. 5046 10 1 (i) (i) The department of health shall establish a program for 2 synchronization of medications when it is agreed among the recipient, a 3 provider and a pharmacist that synchronization of multiple prescriptions 4 for the treatment of a chronic illness is in the best interest of the 5 patient for the management or treatment of a chronic illness provided 6 that the medications: 7 (A) are covered by the department of health pursuant to this title; 8 (B) are used for treatment and management of chronic conditions that 9 are subject to refills; 10 (C) are not a schedule II controlled substance or a schedule III 11 controlled substance containing hydrocodone; 12 (D) meet all prior authorization criteria specific to the medications 13 at the time of the synchronization request; 14 (E) are of a formulation that can be effectively split over required 15 short fill periods to achieve synchronization; and 16 (F) do not have quantity limits or dose optimization criteria or 17 requirements that would be violated in fulfilling synchronization. 18 (ii) The department of health shall not deny coverage for the dispens- 19 ing of a medication by a network pharmacy for a partial supply when it 20 is for the purpose of synchronizing the patient's medications. When 21 applicable to permit synchronization, the department of health shall 22 allow a pharmacy to override any denial codes indicating that a 23 prescription is being refilled too soon for the purposes of medication 24 synchronization. 25 (iii) To permit synchronization, the department of health shall apply 26 a prorated daily cost-sharing rate to any medication dispensed by a 27 network pharmacy pursuant to this section. 28 (iv) The dispensing fee paid to a network pharmacy contracted to 29 provide services pursuant to this section for a partial supply associ- 30 ated with a medication synchronization shall be paid in full and shall 31 not be prorated. 32 (v) The requirements of this paragraph applies only once for each 33 prescription drug subject to medication synchronization except when 34 either of the following occurs: 35 (A) the prescriber changes the dosage or frequency of administration 36 of the prescription drug subject to a medication synchronization; or 37 (B) the prescriber prescribes a different drug. 38 (vi) Nothing in this paragraph shall be deemed to require health care 39 practitioners and pharmacists to synchronize the refilling of multiple 40 prescriptions for a recipient. 41 § 15. Subdivision 4 of section 364-j of the social services law is 42 amended by adding a new paragraph (w) to read as follows: 43 (w) (i) The department of health or a managed care organization 44 contracted to provide services pursuant to this section shall establish 45 a program for synchronization of medications when it is agreed among the 46 recipient, a provider and a pharmacist that synchronization of multiple 47 prescriptions for the treatment of a chronic illness is in the best 48 interest of the patient for the management or treatment of a chronic 49 illness provided that the medications: 50 (A) are covered by Medicaid services or a managed care organization 51 contracted to provide services pursuant to this chapter; 52 (B) are used for treatment and management of chronic conditions that 53 are subject to refills; 54 (C) are not a schedule II controlled substance or a schedule III 55 controlled substance containing hydrocodone;A. 5046 11 1 (D) meet all prior authorization criteria specific to the medications 2 at the time of the synchronization request; 3 (E) are of a formulation that can be effectively split over required 4 short fill periods to achieve synchronization; and 5 (F) do not have quantity limits or dose optimization criteria or 6 requirements that would be violated in fulfilling synchronization. 7 (ii) The department of health or a managed care organization 8 contracted to provide services under this section shall not deny cover- 9 age for the dispensing of a medication by a network pharmacy for a 10 partial supply when it is for the purpose of synchronizing the patient's 11 medications. When applicable to permit synchronization, the department 12 of health or a managed care organization contracted to provide services 13 under this title shall allow a pharmacy to override any denial code 14 indicating that a prescription is being refilled too soon for the 15 purposes of medication synchronization. 16 (iii) To permit synchronization, the department of health or a managed 17 care organization contracted to provide services pursuant to this title 18 shall apply a prorated daily cost-sharing rate to any medication 19 dispensed by a network pharmacy pursuant to this section. 20 (iv) The dispensing fee paid to a network pharmacy contracted to 21 provide services pursuant to this section for a partial supply associ- 22 ated with a medication synchronization shall be paid in full and shall 23 not be prorated. 24 (v) The requirements of this paragraph applies only once for each 25 prescription drug subject to medication synchronization except when 26 either of the following occurs: 27 (A) the prescriber changes the dosage or frequency of administration 28 of the prescription drug subject to a medication synchronization; or 29 (B) the prescriber prescribes a different drug. 30 (vi) Nothing in this paragraph shall be deemed to require health care 31 practitioners and pharmacists to synchronize the refilling of multiple 32 prescriptions for a covered individual. 33 § 16. Subsection (h) of section 4325 of the insurance law, as added by 34 chapter 487 of the laws of 2010, is amended to read as follows: 35 (h) (i) No corporation or insurer organized or licensed under this 36 chapter which provides coverage for prescription drugs shall require, or 37 enter into a contract which permits, a copayment which exceeds the usual 38 and customary cost of such prescribed drug or which exceeds the total 39 price paid to the pharmacy for such prescribed drug after the insured 40 has met the annual deductible requirement. 41 (ii) In determining any coinsurance amount required to be paid for a 42 prescription drug, no insurer or corporation organized under this chap- 43 ter shall base its computation on a price higher than the actual price 44 paid by the pharmacy for the drug, taking into account any rebates 45 specific to the drug. The department of financial services shall issue 46 regulations setting forth the method each insurer or corporation organ- 47 ized under this chapter must use to determine the actual price paid by 48 the pharmacy. 49 (iii) Each insurer or corporation licensed under this article which 50 offers prescription drug coverage must itself or through its pharmacy 51 benefit manager issue a written explanation of benefit form to its 52 enrollees with respect to each prescription filled, containing all cate- 53 gories of information required of explanation of benefits forms for 54 medical benefits. 55 § 17. Subdivision 6 of section 6810 of the education law is amended by 56 adding a new paragraph (b-1) to read as follows:A. 5046 12 1 (b-1) The prescriber or pharmacist shall inform the patient whether he 2 or she has prescribed or substituted a different generic drug product 3 from the generic drug product the patient has previously received. 4 Notification required pursuant to this paragraph shall be provided both 5 written and orally, contemporaneously with the filling of the 6 prescription. 7 § 18. Section 6826-a of the education law is amended by adding a new 8 subdivision 3 to read as follows: 9 3. The copayment amount shall not exceed the total price paid to the 10 pharmacy for the prescribed drug, except in cases where the insured has 11 not met the annual deductible requirement. The copayment charged to a 12 consumer for a prescription drug shall not exceed the amount which would 13 be charged if the drug were purchased without insurance coverage. 14 § 19. Paragraph 1 of subsection (e) of section 3231 of the insurance 15 law is amended by adding a new subparagraph (C) to read as follows: 16 (C) an insurer shall annually certify to the department that, during 17 the prior benefit year, the insurer made available to enrollees at the 18 point of sale at least a majority (i.e., greater than fifty percent) of 19 the rebates. 20 (i) For purposes of this subparagraph, "rebate" means: 21 (1) negotiated price concessions including but not limited to base 22 rebates and reasonable estimates of any price protection rebates and 23 performance-based rebates that may accrue directly or indirectly to the 24 issuer during the coverage year from a manufacturer, dispensing pharma- 25 cy, or other party to the transaction; and 26 (2) reasonable estimates of any fees and other administrative costs 27 that are passed through to the issuer and serve to reduce the issuer's 28 prescription drug liabilities for the coverage year. 29 (ii) In providing the certification required under this section, an 30 issuer shall not publish or otherwise reveal information regarding the 31 actual amount of rebates the issuer received on a product-, manufactur- 32 er-, or pharmacy-specific basis. Such information is protected as a 33 trade secret, is not a public record as defined in the public officers 34 law and shall not be disclosed directly or indirectly. An insurer shall 35 impose the confidentiality protections of this section on any third 36 parties or vendors with which it contracts that may receive or have 37 access to rebate information. 38 § 20. Subsection (b) of section 3221 of the insurance law is amended 39 to read as follows: 40 (b) (1) No such policy shall be delivered or issued for delivery in 41 this state unless a schedule of the premium rates pertaining to such 42 form shall have been filed with the superintendent. 43 (2) An insurer shall annually certify to the department that, during 44 the prior benefit year, the insurer made available to enrollees at the 45 point of sale at least a majority (i.e., greater than fifty percent) of 46 the rebates. 47 (A) For purposes of this paragraph, "rebate" means: 48 (i) Negotiated price concessions including but not limited to base 49 rebates and reasonable estimates of any price protection rebates and 50 performance-based rebates that may accrue directly or indirectly to the 51 issuer during the coverage year from a manufacturer, dispensing pharma- 52 cy, or other party to the transaction; and 53 (ii) Reasonable estimates of any fees and other administrative costs 54 that are passed through to the issuer and serve to reduce the issuer's 55 prescription drug liabilities for the coverage year.A. 5046 13 1 (B) In providing the certification required under this section, an 2 issuer shall not publish or otherwise reveal information regarding the 3 actual amount of rebates the issuer received on a product-, manufactur- 4 er-, or pharmacy-specific basis. Such information is protected as a 5 trade secret, is not a public record as defined in the public officers 6 law and shall not be disclosed directly or indirectly. An insurer shall 7 impose the confidentiality protections of this section on any third 8 parties or vendors with which it contracts that may receive or have 9 access to rebate information. 10 § 21. Severability. If any item, clause, sentence, subparagraph, 11 subdivision or other part of this act, or the application thereof to any 12 person or circumstances shall be held to be invalid, such holding shall 13 not affect, impair or invalidate the remainder of this act but it shall 14 be confined in its operation to the item, clause, sentence, subpara- 15 graph, subdivision or other part of this act directly involved in such 16 holding, or to the person and circumstances therein involved. 17 § 22. This act shall take effect immediately and shall apply to insur- 18 ance policies issued, amended, or renewed on or after January 1, 2022; 19 provided, however, that the amendments to subdivision 9 of section 367-a 20 of the social services law made by section fourteen of this act shall 21 not affect the expiration of such subdivision pursuant to section 4 of 22 chapter 19 of the laws of 1998, as amended, and shall expire therewith; 23 and provided, further, that the amendments to section 364-j of the 24 social services law made by section fifteen of this act shall not affect 25 the repeal of such section and shall be deemed repealed therewith. 26 Effective immediately the addition, amendment or repeal of any rule or 27 regulation necessary for the implementation of this act on its effective 28 date are authorized to be made and completed on or before such date.
