Bill Text: NY A08067 | 2023-2024 | 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 10-1)

Status: (Introduced) 2024-01-03 - referred to insurance [A08067 Detail]

Download: New_York-2023-A08067-Introduced.html



                STATE OF NEW YORK
        ________________________________________________________________________

                                          8067

                               2023-2024 Regular Sessions

                   IN ASSEMBLY

                                   September 27, 2023
                                       ___________

        Introduced  by  M.  of  A.  SOLAGES,  TAYLOR,  SEAWRIGHT,  RAMOS, SIMON,
          L. ROSENTHAL, GLICK, 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 4807
     2  to read as follows:
     3    § 4807. 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
    17  accordance with article forty-nine of this chapter,  including  external
    18  appeal.

         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD10957-02-3

        A. 8067                             2

     1    (b)  (1)  For  purposes of this section, "prior authorization require-
     2  ment" means any practice implemented by an insurer in which coverage  of
     3  a  prescription  drug  or device is dependent upon a covered person or a
     4  health care practitioner obtaining approval from the  insurer  prior  to
     5  the  service,  device, or drug being performed, received, or prescribed,
     6  as applicable. "Prior authorization" includes prospective or utilization
     7  review procedures conducted prior to providing a drug or device.
     8    (2) An insurer which  requires  prior  authorizations  for  particular
     9  prescription  drugs  shall  have  a procedure by which an insured who is
    10  being prescribed such drug for a chronic condition may obtain a standing
    11  prior authorization for a drug for the lesser of the following from  the
    12  date  of  the  approval:  (i) twelve months; or (ii) the last day of the
    13  covered person's eligibility under the policy or plan.
    14    (3) As a condition of such standing prior authorization, if  according
    15  to  the  available medical and scientific evidence the patient's chronic
    16  condition is likely to change during the standing referral  period,  the
    17  insurer  or  health plan may require the prescribing health care practi-
    18  tioner to certify to the insurer, not more frequently than on a quarter-
    19  ly basis, that the patient's chronic condition  has  not  changed  mate-
    20  rially with respect to the need for the prescription.
    21    (4)  A  twelve-month standing prior authorization provided under para-
    22  graph two of this subsection does not apply to and is not  required  for
    23  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    (5) 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    (6) 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    (7)  If an AB-rated generic drug that is therapeutically equivalent to
    45  the drug subject to a standing prior  authorization  becomes  available,
    46  the insurer may substitute such newly released drug for the drug subject
    47  to the standing prior authorization, provided advance notice is given to
    48  the insured.
    49    (8)  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    (c) (1) If a formulary drug being prescribed for an insured is removed
    55  by the insurer from its formulary for reasons other than a determination
    56  that the approval for the use of that drug has  been  withdrawn  by  the

        A. 8067                             3

     1  U.S.  Food  and Drug Administration, the insurer shall continue to cover
     2  that drug for that insured for a transitional period to the end  of  the
     3  plan  year  at the same copayment as charged when the drug was on formu-
     4  lary.   Thereafter, the insured may seek continued coverage of the drug,
     5  if appropriate, pursuant to the provisions of  subsection  (a)  of  this
     6  section.
     7    (2)  If  a  formulary drug being prescribed for an insured is moved by
     8  the insurer to a higher cost sharing tier in its formulary  for  reasons
     9  other  than  release  of  an  AB-rated  generic  drug, the insurer shall
    10  continue to cover that drug for that insured for a  transitional  period
    11  to  the  end  of the plan year at the same copayment as charged when the
    12  drug was on formulary. Thereafter, the insured may seek continued cover-
    13  age  of  the  drug,  if  appropriate,  pursuant  to  the  provisions  of
    14  subsection (a) of this section.
    15    (3)  If  an insurer that provides prescription drug coverage enrolls a
    16  new insured who is currently being  prescribed  a  drug  for  a  chronic
    17  health  condition,  or  as part of an ongoing course of treatment for an
    18  acute condition, and that drug is not on the  insurer's  formulary,  the
    19  insurer  shall cover that drug for that insured at no additional cost to
    20  the insured beyond what the insured would otherwise pay for a  preferred
    21  brand  name  drug  on the formulary, for a transitional period of ninety
    22  (90) days from the effective date of enrollment. The insured must adhere
    23  to the insurer's quality  assurance  requirements  and  provide  to  the
    24  insurer  necessary  medical  information related to the prescription and
    25  otherwise adhere to the insurer's policies and procedures including, but
    26  not limited to procedures regarding obtaining  pre-authorization  and  a
    27  treatment  plan  approved  by  the  insurer.  In  no  event  shall  this
    28  subsection be construed to require an insurer to  provide  coverage  for
    29  benefits  not  otherwise  covered.  The  transitional  period  does  not
    30  preclude the insured from seeking continued coverage  of  the  drug,  if
    31  appropriate,  pursuant  to  the  provisions  of  subsection  (a) of this
    32  section.
    33    § 2. The public health law is amended by adding a new  section  4406-j
    34  to read as follows:
    35    §  4406-j. Access to appropriate drugs at reasonable prices; formulary
    36  exceptions; standing prior authorization requirement. 1. A health  main-
    37  tenance  organization offering a prescription drug benefit with a formu-
    38  lary of approved or preferred drugs shall have a procedure by  which  it
    39  determines  whether  a  formulary  drug provides appropriate therapeutic
    40  benefits to meet the particular health care needs of an enrollee. If the
    41  health  maintenance  organization  determines  that  no  formulary  drug
    42  provides  appropriate therapeutic benefits to meet the particular health
    43  care needs of an enrollee, the  health  maintenance  organization  shall
    44  cover  the  cost of an off-formulary drug for that enrollee, at no addi-
    45  tional cost to the enrollee beyond what the enrollee would otherwise pay
    46  for a preferred brand name drug on  the  formulary.  The  determinations
    47  whether  a  drug provides appropriate therapeutic benefits and whether a
    48  non-formulary drug is necessary to meet the particular health care needs
    49  of the insured are utilization review decisions and  are  reviewable  in
    50  accordance  with  article forty-nine of this chapter, including external
    51  appeal.
    52    2. (a) For purposes of this section, "prior authorization requirement"
    53  means any practice implemented by a health maintenance  organization  in
    54  which  coverage  of  a  prescription  drug or device is dependent upon a
    55  covered person or a health care practitioner obtaining approval from the
    56  health maintenance organization prior to the service,  device,  or  drug

        A. 8067                             4

     1  being performed, received, or prescribed, as applicable. "Prior authori-
     2  zation"  includes prospective or utilization review procedures conducted
     3  prior to providing a drug or device.
     4    (b)  A  health  maintenance organization which requires prior authori-
     5  zations for particular prescription drugs  shall  have  a  procedure  by
     6  which an enrollee who is being prescribed such drug for a chronic condi-
     7  tion may obtain a standing prior authorization for a drug for the lesser
     8  of the following from the date of the approval:  (i) twelve months; (ii)
     9  the last day of the enrollee's eligibility under the policy or plan.
    10    (c)  As a condition of such standing prior authorization, if according
    11  to the available medical and scientific evidence the enrollee's  chronic
    12  condition  is  likely to change during the standing referral period, the
    13  insurer or health plan may require the prescribing health  care  practi-
    14  tioner  to  certify  to  the  health  maintenance organization, not more
    15  frequently than on a quarterly basis, that the enrollee's chronic condi-
    16  tion has not changed  materially  with  respect  to  the  need  for  the
    17  prescription.
    18    (d) A twelve-month standing prior authorization provided under subpar-
    19  agraph (i) of paragraph (b) of this subdivision does not apply to and is
    20  not required for any of the following:
    21    (i)  medications  that have a typical course of administration of less
    22  than one year or for which available medical or scientific evidence does
    23  not support a twelve-month period of use, in  which  case  the  standing
    24  prior authorization period shall be the typical course of administration
    25  or  the  period  of use supported by the available medical or scientific
    26  evidence;
    27    (ii) medications that require an initial  trial  period  to  determine
    28  effectiveness  and  tolerability,  except that after such trial period a
    29  one-year, or greater, prior authorization period will be given; and
    30    (iii) medications that are schedule II controlled substance or a sche-
    31  dule III controlled substance containing hydrocodone.
    32    (e) For drugs used to treat acute  conditions,  insurers  shall  grant
    33  standing prior authorizations for the period that the medical and scien-
    34  tific  evidence  shows  to  be  the anticipated period for the course of
    35  treatment to have its intended effect.
    36    (f) The standing prior authorizations provided for in this section are
    37  no longer valid and automatically terminate  if  there  are  changes  to
    38  federal  or  state  laws  or  federal  regulatory guidance or compliance
    39  information finding that the drug in question is no longer  approved  or
    40  safe for the prescribed purpose.
    41    (g)  If an AB-rated generic drug that is therapeutically equivalent to
    42  the drug subject to a standing prior  authorization  becomes  available,
    43  the  health  maintenance organization may substitute such newly released
    44  drug for the drug subject to the standing prior authorization,  provided
    45  advance notice is given to the enrollee.
    46    (h)  The determination whether the drug is being prescribed to treat a
    47  chronic condition and the period over which the course of treatment  for
    48  an acute condition is anticipated to have its intended effect are utili-
    49  zation  review  decisions  and are reviewable in accordance with article
    50  forty-nine of this chapter, including external appeal.
    51    3. (a) If a formulary drug being prescribed for an enrollee is removed
    52  by the health maintenance organization from its  formulary  for  reasons
    53  other  than  a  determination that the approval for the use of that drug
    54  has been withdrawn by the U.S.  Food and Drug Administration, the health
    55  maintenance organization shall continue to  cover  that  drug  for  that
    56  enrollee  for  a  transitional period to the end of the plan year at the

        A. 8067                             5

     1  same copayment as charged when the drug was  on  formulary.  Thereafter,
     2  the  enrollee  may  seek continued coverage of the drug, if appropriate,
     3  pursuant to the provisions of subdivision one of this section.
     4    (b)  If  a  formulary drug being prescribed for an insured is moved by
     5  the health maintenance organization to a higher cost sharing tier in its
     6  formulary for reasons other than release of an  AB-rated  generic  drug,
     7  the  health  maintenance  organization shall continue to cover that drug
     8  for that enrollee for a transitional period to the end of the plan  year
     9  at the same copayment as charged when the drug was on formulary.  There-
    10  after,  the  enrollee may seek continued coverage of the drug, if appro-
    11  priate, pursuant to the provisions of subdivision one of this section.
    12    (c) If a health maintenance organization  that  provides  prescription
    13  drug coverage enrolls a new enrollee who is currently being prescribed a
    14  drug  for a chronic health condition, or as part of an ongoing course of
    15  treatment for an acute condition, and that drug is  not  on  the  health
    16  maintenance  organization's  formulary, the health maintenance organiza-
    17  tion shall cover that drug for that enrollee at no  additional  cost  to
    18  the  enrollee  beyond  what  the  enrollee  would  otherwise  pay  for a
    19  preferred brand name drug on the formulary, for a transitional period of
    20  ninety (90) days from the effective date  of  enrollment.  The  enrollee
    21  must  adhere  to the health maintenance organization's quality assurance
    22  requirements and provide to the health maintenance  organization  neces-
    23  sary  medical  information  related  to  the  prescription and otherwise
    24  adhere to the health maintenance organization's policies and  procedures
    25  including, but not limited to procedures regarding obtaining pre-author-
    26  ization  and  a treatment plan approved by the health maintenance organ-
    27  ization. In no event shall this subdivision be construed  to  require  a
    28  health  maintenance  organization  to  provide coverage for benefits not
    29  otherwise covered.  The transitional period does not preclude the enrol-
    30  lee from seeking continued coverage of the drug, if appropriate,  pursu-
    31  ant to the provisions of subdivision one of this section.
    32    §  3.  Section  4903  of  the insurance law is amended by adding a new
    33  subsection (j) to read as follows:
    34    (j) (1) Each health plan shall make  available  to  all  participating
    35  health  care  providers  on its web site or provider portal a listing of
    36  its prior authorization requirements, including specific information  or
    37  documentation that a provider must submit in order for the prior author-
    38  ization request to be considered complete.
    39    (2)  Each health plan shall make available on its web site information
    40  about the policies, contracts, or agreements offered by it that  clearly
    41  identifies specific services, drugs, or devices to which a prior author-
    42  ization requirement exists.
    43    (3)  Each  health  plan  shall  give  thirty (30) days advance written
    44  notice to participating providers of any changes in prior  authorization
    45  requirements.  Each health plan shall also give thirty (30) days advance
    46  written notice to plan participants of any  changes  in  prior  authori-
    47  zation requirements with respect to any services, drugs or devices which
    48  such participant is currently being prescribed or has been prescribed in
    49  the preceding year.
    50    §  4. Section 4903 of the public health law is amended by adding a new
    51  subdivision 10 to read as follows:
    52    10. (a) Each health plan shall make  available  to  all  participating
    53  health  care  providers  on its web site or provider portal a listing of
    54  its prior authorization requirements, including specific information  or
    55  documentation that a provider must submit in order for the prior author-
    56  ization request to be considered complete.

        A. 8067                             6

     1    (b)  Each health plan shall make available on its web site information
     2  about the policies, contracts, or agreements offered by it that  clearly
     3  identifies specific services, drugs, or devices to which a prior author-
     4  ization requirement exists.
     5    (c)  Each  health  plan  shall  give  thirty (30) days advance written
     6  notice to participating providers of any changes in prior  authorization
     7  requirements.  Each health plan shall also give thirty (30) days advance
     8  written notice to plan participants of any  changes  in  prior  authori-
     9  zation requirements with respect to any services, drugs or devices which
    10  such participant is currently being prescribed or has been prescribed in
    11  the preceding year.
    12    § 5. Subsection (b) of section 4910 of the insurance law is amended by
    13  adding a new paragraph 5 to read as follows:
    14    (5)  (A)  The insured has had a drug prescription denied on the ground
    15  that it is not on the health care plan's formulary, and that the  health
    16  care plan has a covered drug on the formulary which is effective to meet
    17  the particular health care needs of an insured; and
    18    (B)  The insured's attending physician, who shall be a licensed physi-
    19  cian or other health care provider qualified to prescribe drugs to treat
    20  the insured for the health  service  sought,  certifies  that  available
    21  formulary  drugs  are  not  sufficiently effective to meet the insured's
    22  health needs, or are otherwise  contraindicated  for  the  insured,  and
    23  recommends  an  off-formulary  drug  that will be effective to treat the
    24  insured.
    25    § 6. Subdivision 2 of section 4910 of the public health law is amended
    26  by adding a new paragraph (e) to read as follows:
    27    (e) (i) The enrollee has had a drug prescription denied on the  ground
    28  that  it  is not on the health maintenance organization's formulary, and
    29  that the health maintenance organization  has  a  covered  drug  on  the
    30  formulary which is effective to meet the particular health care needs of
    31  an enrollee; and
    32    (ii)  The  enrollee's  attending  physician,  who  shall be a licensed
    33  physician or other health care provider qualified to prescribe drugs  to
    34  treat  the  insured for the health service sought, certifies that avail-
    35  able  formulary  drugs  are  not  sufficiently  effective  to  meet  the
    36  enrollee's health needs, or are otherwise contraindicated for the enrol-
    37  lee,  and  recommends  an  off-formulary  drug that will be effective to
    38  treat the enrollee.
    39    § 7. Paragraph 4 of subsection (b) of section 4914  of  the  insurance
    40  law is amended by adding a new subparagraph (E) to read as follows:
    41    (E)  For  external  appeals  requested  pursuant  to paragraph five of
    42  subsection (b) of section four thousand nine hundred ten of  this  title
    43  relating  to  an  off-formulary  drug  denial, the external appeal agent
    44  shall review the utilization review agent's final adverse  determination
    45  and,  in  accordance  with  the  provisions  of this title, shall make a
    46  determination as to whether the non-formulary drug shall be  covered  by
    47  the health plan; provided that such determination shall:
    48    (i)  be conducted only by one or a greater odd number of clinical peer
    49  reviewers;
    50    (ii) be accompanied by a written statement:
    51    (I) that the off-formulary drug prescription shall be covered  by  the
    52  health  care plan either when the reviewer or a majority of the panel of
    53  reviewers determines, upon review of the available medical and scientif-
    54  ic evidence, the formulary drug deemed sufficient  by  the  health  plan
    55  will  not be as effective in addressing the insured's health problem for
    56  which a drug has been prescribed as the off-formulary drug prescribed by

        A. 8067                             7

     1  the treating physician or otherwise be appropriate to meet  the  partic-
     2  ular health care needs of the insured, which is more likely to provide a
     3  beneficial clinical outcome; or
     4    (II) upholding the health plan's denial of coverage.
     5    §  8.  Paragraph  (d)  of  subdivision 2 of section 4914 of the public
     6  health law is amended by adding  a  new  subparagraph  (E)  to  read  as
     7  follows:
     8    (E) For external appeals requested pursuant to paragraph (e) of subdi-
     9  vision  two  of section forty-nine hundred ten of this title relating to
    10  an off-formulary drug denial, the external appeal agent shall review the
    11  utilization review agent's final adverse determination and,  in  accord-
    12  ance with the provisions of this title, shall make a determination as to
    13  whether  the  non-formulary  drug shall be covered by the health mainte-
    14  nance organization; provided that such determination shall:
    15    (i) be conducted only by one or a greater odd number of clinical  peer
    16  reviewers;
    17    (ii) be accompanied by a written statement:
    18    (1)  that  the off-formulary drug prescription shall be covered by the
    19  health maintenance organization either when the reviewer or  a  majority
    20  of  the  panel  of  reviewers  determines,  upon review of the available
    21  medical and scientific evidence, the formulary drug deemed sufficient by
    22  the health maintenance organization will not be as effective in address-
    23  ing the enrollee's health problem for which a drug has  been  prescribed
    24  as the off-formulary drug prescribed by the treating physician or other-
    25  wise  be  appropriate  to  meet  the particular health care needs of the
    26  enrollee, which is more likely to provide a beneficial clinical outcome;
    27  or
    28    (2) upholding the health maintenance organization's denial  of  cover-
    29  age.
    30    §  9.  The  opening  paragraph  of  paragraph  28 of subsection (i) of
    31  section 3216 of the insurance law is designated subparagraph (A)  and  a
    32  new subparagraph (B) is added to read as follows:
    33    (B)  Notwithstanding any other provision of this paragraph, if a pres-
    34  criber, after consulting with the insurer regarding the  appropriateness
    35  of  mail order delivery given: (i) the residence or delivery location of
    36  the insured; (ii) the medical condition of the insured; (iii) the  stor-
    37  age  requirements  of  the drug; (iv) the availability of the insured to
    38  receive the prescription; or (v) the  insured's  ability  to  comprehend
    39  pharmaceutical  guidance and support over the telephone, determines that
    40  a drug as prescribed on an individual basis is most appropriately filled
    41  at a retail location, provided that an in-network retail pharmacy of the
    42  patient's choosing agrees to the same reimbursement amount and  is  able
    43  to fill the prescription, the prescriber's determination shall be final.
    44    §  10.  The  opening  paragraph  of  paragraph 18 of subsection (1) of
    45  section 3221 of the insurance law is designated subparagraph (A)  and  a
    46  new subparagraph (B) is added to read as follows:
    47    (B)  Notwithstanding any other provision of this paragraph, if a pres-
    48  criber, after consulting with the insurer regarding the  appropriateness
    49  of  mail order delivery given: (i) the residence or delivery location of
    50  the insured; (ii) the medical condition of the insured; (iii) the  stor-
    51  age  requirements  of  the drug; (iv) the availability of the insured to
    52  receive the prescription; or (v) the  insured's  ability  to  comprehend
    53  pharmaceutical  guidance and support over the telephone, determines that
    54  a drug as prescribed on an individual basis is most appropriately filled
    55  at a retail location, provided that an in-network retail pharmacy of the

        A. 8067                             8

     1  patient's choosing agrees to the same reimbursement amount and  is  able
     2  to fill the prescription, the prescriber's determination shall be final.
     3    §  11. Subsection (kk) of section 4303 of the insurance law is amended
     4  by adding a new paragraph 3 to read as follows:
     5    (3) Notwithstanding any other provision of this subsection, if a pres-
     6  criber, after consulting with the insurer regarding the  appropriateness
     7  of  mail order delivery given: (A) the residence or delivery location of
     8  the covered person; (B) the medical condition of the covered person; (C)
     9  the storage requirements of  the  drug;  (D)  the  availability  of  the
    10  covered  person to receive the prescription; or (E) the covered person's
    11  ability to comprehend pharmaceutical guidance and support over the tele-
    12  phone, determines that a drug as prescribed on an  individual  basis  is
    13  most appropriately filled at a retail location, provided that an in-net-
    14  work  retail  pharmacy  of  the  patient's  choosing  agrees to the same
    15  reimbursement  amount  and  is  able  to  fill  the  prescription,   the
    16  prescriber's determination shall be final.
    17    §  12.  The insurance law is amended by adding a new section 3224-e to
    18  read as follows:
    19    § 3224-e. Prescription synchronization. (a) Every individual or  group
    20  health insurance policy providing prescription drug coverage when appli-
    21  cable  to permit synchronization shall permit and apply a daily prorated
    22  cost-sharing rate to prescriptions that are dispensed by a network phar-
    23  macy for less than a thirty day supply, when  it  is  agreed  among  the
    24  covered  individual,  a  health care practitioner, and a pharmacist that
    25  synchronization of multiple prescriptions for the treatment of a chronic
    26  illness is in the best  interest  of  the  covered  individual  for  the
    27  management or treatment of that chronic illness provided that all of the
    28  following apply:
    29    (1) the medications are covered by the policy or plan;
    30    (2)  the  medications are used for treatment and management of chronic
    31  conditions that are subject to refills;
    32    (3) the medications are not a schedule II controlled  substance  or  a
    33  schedule III controlled substance containing hydrocodone;
    34    (4)  the medications meet all prior authorization criteria specific to
    35  medications at the time of the synchronization request;
    36    (5) the medications are of a formulation that can be effectively split
    37  over required short fill periods to achieve synchronization; and
    38    (6) the medications do not have quantity limits or  dose  optimization
    39  criteria or requirements that would be violated in fulfilling synchroni-
    40  zation.
    41    (b)   No   individual  or  group  health  insurance  policy  providing
    42  prescription drug coverage shall deny coverage for the dispensing  of  a
    43  medication for partial fill when it is for purposes of synchronizing the
    44  patient's  medications. When applicable to permit synchronization, every
    45  individual or group health insurance policy must  allow  a  pharmacy  to
    46  override  any  denial  codes  indicating  that  a  prescription is being
    47  refilled too soon for the purposes of medication synchronization.
    48    (c) Dispensing fees for partially  filled  or  refilled  prescriptions
    49  shall be paid in full for each prescription dispensed, regardless of any
    50  pro-rated copay for the beneficiary or fee paid for alignment services.
    51    (d)  Nothing  in  this  section shall be deemed to require health care
    52  practitioners and pharmacists to synchronize the refilling  of  multiple
    53  prescriptions for a covered individual.
    54    (e)  The  requirements  of this section shall apply only once for each
    55  prescription drug subject  to  medication  synchronization  except  when
    56  either of the following occurs:

        A. 8067                             9

     1    (1)  the  prescriber changes the dosage or frequency of administration
     2  of the prescription drug subject to a medication synchronization; or
     3    (2) the prescriber prescribes a different drug.
     4    §  13.  The insurance law is amended by adding a new section 4303-b to
     5  read as follows:
     6    § 4303-b. Prescription synchronization.  (a)  Every  hospital  service
     7  corporation  and  health service corporation providing prescription drug
     8  coverage when applicable to  permit  synchronization  shall  permit  and
     9  apply  a  daily  prorated  cost-sharing  rate  to prescriptions that are
    10  dispensed by a network pharmacy for less than a thirty day supply,  when
    11  it  is  agreed among the covered individual, a health care practitioner,
    12  and a pharmacist that synchronization of multiple prescriptions for  the
    13  treatment  of  a  chronic illness is in the best interest of the covered
    14  individual for the management  or  treatment  of  that  chronic  illness
    15  provided that all of the following apply:
    16    (1) the medications are covered by the policy or plan;
    17    (2)  the  medications are used for treatment and management of chronic
    18  conditions that are subject to refills;
    19    (3) the medications are not a schedule II controlled  substance  or  a
    20  schedule III controlled substance containing hydrocodone;
    21    (4)  the medications meet all prior authorization criteria specific to
    22  medications at the time of the synchronization request;
    23    (5) the medications are of a formulation that can be effectively split
    24  over required short fill periods to achieve synchronization; and
    25    (6) the medications do not have quantity limits or  dose  optimization
    26  criteria or requirements that would be violated in fulfilling synchroni-
    27  zation.
    28    (b)  No  hospital  service  corporation  or health service corporation
    29  providing  prescription  drug  coverage  shall  deny  coverage  for  the
    30  dispensing  of  a medication for partial fill when it is for purposes of
    31  synchronizing the  patient's  medications.  When  applicable  to  permit
    32  synchronization,  every  hospital  service corporation or health service
    33  corporation providing prescription drug coverage must allow  a  pharmacy
    34  to  override  any  denial  codes indicating that a prescription is being
    35  refilled too soon for the purposes of medication synchronization.
    36    (c) Dispensing fees for partially  filled  or  refilled  prescriptions
    37  shall be paid in full for each prescription dispensed, regardless of any
    38  pro-rated copay for the beneficiary or fee paid for alignment services.
    39    (d)  Nothing  in  this  section shall be deemed to require health care
    40  practitioners and pharmacists to synchronize the refilling  of  multiple
    41  prescriptions for a covered individual.
    42    (e)  The  requirements  of this section shall apply only once for each
    43  prescription drug subject  to  medication  synchronization  except  when
    44  either of the following occurs:
    45    (1)  The  prescriber changes the dosage or frequency of administration
    46  of the prescription drug subject to a medication synchronization; or
    47    (2) The prescriber prescribes a different drug.
    48    § 14. Subdivision 9 of section 367-a of the  social  services  law  is
    49  amended by adding a new paragraph (j) to read as follows:
    50    (j)  (i)  The  department  of  health  shall  establish  a program for
    51  synchronization of medications when it is agreed among the recipient,  a
    52  provider and a pharmacist that synchronization of multiple prescriptions
    53  for  the  treatment  of a chronic illness is in the best interest of the
    54  patient for the management or treatment of a  chronic  illness  provided
    55  that the medications:
    56    (A) are covered by the department of health pursuant to this title;

        A. 8067                            10

     1    (B)  are  used for treatment and management of chronic conditions that
     2  are subject to refills;
     3    (C)  are  not  a  schedule  II  controlled substance or a schedule III
     4  controlled substance containing hydrocodone;
     5    (D) meet all prior authorization criteria specific to the  medications
     6  at the time of the synchronization request;
     7    (E)  are  of a formulation that can be effectively split over required
     8  short fill periods to achieve synchronization; and
     9    (F) do not have quantity  limits  or  dose  optimization  criteria  or
    10  requirements that would be violated in fulfilling synchronization.
    11    (ii) The department of health shall not deny coverage for the dispens-
    12  ing  of  a medication by a network pharmacy for a partial supply when it
    13  is for the purpose of  synchronizing  the  patient's  medications.  When
    14  applicable  to  permit  synchronization,  the department of health shall
    15  allow a  pharmacy  to  override  any  denial  codes  indicating  that  a
    16  prescription  is  being refilled too soon for the purposes of medication
    17  synchronization.
    18    (iii) To permit synchronization, the department of health shall  apply
    19  a  prorated  daily  cost-sharing  rate  to any medication dispensed by a
    20  network pharmacy pursuant to this section.
    21    (iv) The dispensing fee paid  to  a  network  pharmacy  contracted  to
    22  provide  services  pursuant to this section for a partial supply associ-
    23  ated with a medication synchronization shall be paid in full  and  shall
    24  not be prorated.
    25    (v)  The  requirements  of  this  paragraph applies only once for each
    26  prescription drug subject  to  medication  synchronization  except  when
    27  either of the following occurs:
    28    (A)  the  prescriber changes the dosage or frequency of administration
    29  of the prescription drug subject to a medication synchronization; or
    30    (B) the prescriber prescribes a different drug.
    31    (vi) Nothing in this paragraph shall be deemed to require health  care
    32  practitioners  and  pharmacists to synchronize the refilling of multiple
    33  prescriptions for a recipient.
    34    § 15. Subdivision 4 of section 364-j of the  social  services  law  is
    35  amended by adding a new paragraph (x) to read as follows:
    36    (x)  (i)  The  department  of  health  or  a managed care organization
    37  contracted to provide services pursuant to this section shall  establish
    38  a program for synchronization of medications when it is agreed among the
    39  recipient,  a provider and a pharmacist that synchronization of multiple
    40  prescriptions for the treatment of a chronic  illness  is  in  the  best
    41  interest  of  the  patient  for the management or treatment of a chronic
    42  illness provided that the medications:
    43    (A) are covered by Medicaid services or a  managed  care  organization
    44  contracted to provide services pursuant to this chapter;
    45    (B)  are  used for treatment and management of chronic conditions that
    46  are subject to refills;
    47    (C) are not a schedule II  controlled  substance  or  a  schedule  III
    48  controlled substance containing hydrocodone;
    49    (D)  meet all prior authorization criteria specific to the medications
    50  at the time of the synchronization request;
    51    (E) are of a formulation that can be effectively split  over  required
    52  short fill periods to achieve synchronization; and
    53    (F)  do  not  have  quantity  limits  or dose optimization criteria or
    54  requirements that would be violated in fulfilling synchronization.
    55    (ii)  The  department  of  health  or  a  managed  care   organization
    56  contracted  to provide services under this section shall not deny cover-

        A. 8067                            11

     1  age for the dispensing of a medication  by  a  network  pharmacy  for  a
     2  partial supply when it is for the purpose of synchronizing the patient's
     3  medications.  When  applicable to permit synchronization, the department
     4  of  health or a managed care organization contracted to provide services
     5  under this title shall allow a pharmacy  to  override  any  denial  code
     6  indicating  that  a  prescription  is  being  refilled  too soon for the
     7  purposes of medication synchronization.
     8    (iii) To permit synchronization, the department of health or a managed
     9  care organization contracted to provide services pursuant to this  title
    10  shall  apply  a  prorated  daily  cost-sharing  rate  to  any medication
    11  dispensed by a network pharmacy pursuant to this section.
    12    (iv) The dispensing fee paid  to  a  network  pharmacy  contracted  to
    13  provide  services  pursuant to this section for a partial supply associ-
    14  ated with a medication synchronization shall be paid in full  and  shall
    15  not be prorated.
    16    (v)  The  requirements  of  this  paragraph applies only once for each
    17  prescription drug subject  to  medication  synchronization  except  when
    18  either of the following occurs:
    19    (A)  the  prescriber changes the dosage or frequency of administration
    20  of the prescription drug subject to a medication synchronization; or
    21    (B) the prescriber prescribes a different drug.
    22    (vi) Nothing in this paragraph shall be deemed to require health  care
    23  practitioners  and  pharmacists to synchronize the refilling of multiple
    24  prescriptions for a covered individual.
    25    § 16. Subsection (h) of section 4325 of the insurance law, as added by
    26  chapter 487 of the laws of 2010, is amended to read as follows:
    27    (h) (i) No corporation or insurer organized  or  licensed  under  this
    28  chapter which provides coverage for prescription drugs shall require, or
    29  enter into a contract which permits, a copayment which exceeds the usual
    30  and  customary  cost  of such prescribed drug or which exceeds the total
    31  price paid to the pharmacy for such prescribed drug  after  the  insured
    32  has met the annual deductible requirement.
    33    (ii)  In  determining any coinsurance amount required to be paid for a
    34  prescription drug, no insurer or corporation organized under this  chap-
    35  ter  shall  base its computation on a price higher than the actual price
    36  paid by the pharmacy for the  drug,  taking  into  account  any  rebates
    37  specific  to  the drug. The department of financial services shall issue
    38  regulations setting forth the method each insurer or corporation  organ-
    39  ized  under  this chapter must use to determine the actual price paid by
    40  the pharmacy.
    41    (iii) Each insurer or corporation licensed under  this  article  which
    42  offers  prescription  drug  coverage must itself or through its pharmacy
    43  benefit manager issue a written  explanation  of  benefit  form  to  its
    44  enrollees with respect to each prescription filled, containing all cate-
    45  gories  of  information  required  of  explanation of benefits forms for
    46  medical benefits.
    47    § 17. Subdivision 6 of section 6810 of the education law is amended by
    48  adding a new paragraph (b-1) to read as follows:
    49    (b-1) The prescriber or pharmacist shall inform the patient whether he
    50  or she has prescribed or substituted a different  generic  drug  product
    51  from  the  generic  drug  product  the  patient has previously received.
    52  Notification required pursuant to this paragraph shall be provided  both
    53  written   and   orally,   contemporaneously  with  the  filling  of  the
    54  prescription.
    55    § 18. Section 6826-a of the education law is amended by adding  a  new
    56  subdivision 3 to read as follows:

        A. 8067                            12

     1    3.  The  copayment amount shall not exceed the total price paid to the
     2  pharmacy for the prescribed drug, except in cases where the insured  has
     3  not  met  the  annual deductible requirement. The copayment charged to a
     4  consumer for a prescription drug shall not exceed the amount which would
     5  be charged if the drug were purchased without insurance coverage.
     6    §  19.  Paragraph 1 of subsection (e) of section 3231 of the insurance
     7  law is amended by adding a new subparagraph (C) to read as follows:
     8    (C) an insurer shall annually certify to the department  that,  during
     9  the  prior  benefit year, the insurer made available to enrollees at the
    10  point of sale at least a majority (i.e., greater than fifty percent)  of
    11  the rebates.
    12    (i) For purposes of this subparagraph, "rebate" means:
    13    (1)  negotiated  price  concessions  including but not limited to base
    14  rebates and reasonable estimates of any  price  protection  rebates  and
    15  performance-based  rebates that may accrue directly or indirectly to the
    16  issuer during the coverage year from a manufacturer, dispensing  pharma-
    17  cy, or other party to the transaction; and
    18    (2)  reasonable  estimates  of any fees and other administrative costs
    19  that are passed through to the issuer and serve to reduce  the  issuer's
    20  prescription drug liabilities for the coverage year.
    21    (ii)  In  providing  the certification required under this section, an
    22  issuer shall not publish or otherwise reveal information  regarding  the
    23  actual  amount of rebates the issuer received on a product-, manufactur-
    24  er-, or pharmacy-specific basis.   Such information is  protected  as  a
    25  trade  secret,  is not a public record as defined in the public officers
    26  law and shall not be disclosed directly or indirectly. An insurer  shall
    27  impose  the  confidentiality  protections  of  this section on any third
    28  parties or vendors with which it contracts  that  may  receive  or  have
    29  access to rebate information.
    30    §  20.  Subsection (b) of section 3221 of the insurance law is amended
    31  to read as follows:
    32    (b) (1) No such policy shall be delivered or issued  for  delivery  in
    33  this  state  unless  a  schedule of the premium rates pertaining to such
    34  form shall have been filed with the superintendent.
    35    (2) An insurer shall annually certify to the department  that,  during
    36  the  prior  benefit year, the insurer made available to enrollees at the
    37  point of sale at least a majority (i.e., greater than fifty percent)  of
    38  the rebates.
    39    (A) For purposes of this paragraph, "rebate" means:
    40    (i)  Negotiated  price  concessions  including but not limited to base
    41  rebates and reasonable estimates of any  price  protection  rebates  and
    42  performance-based  rebates that may accrue directly or indirectly to the
    43  issuer during the coverage year from a manufacturer, dispensing  pharma-
    44  cy, or other party to the transaction; and
    45    (ii)  Reasonable  estimates of any fees and other administrative costs
    46  that are passed through to the issuer and serve to reduce  the  issuer's
    47  prescription drug liabilities for the coverage year.
    48    (B)  In  providing  the  certification required under this section, an
    49  issuer shall not publish or otherwise reveal information  regarding  the
    50  actual  amount of rebates the issuer received on a product-, manufactur-
    51  er-, or pharmacy-specific basis.   Such information is  protected  as  a
    52  trade  secret,  is not a public record as defined in the public officers
    53  law and shall not be disclosed directly or indirectly. An insurer  shall
    54  impose  the  confidentiality  protections  of  this section on any third
    55  parties or vendors with which it contracts  that  may  receive  or  have
    56  access to rebate information.

        A. 8067                            13

     1    §  21.  Severability.  If  any  item,  clause, sentence, subparagraph,
     2  subdivision or other part of this act, or the application thereof to any
     3  person or circumstances shall be held to be invalid, such holding  shall
     4  not  affect, impair or invalidate the remainder of this act but it shall
     5  be  confined  in  its  operation to the item, clause, sentence, subpara-
     6  graph, subdivision or other part of this act directly involved  in  such
     7  holding, or to the person and circumstances therein involved.
     8    § 22. This act shall take effect immediately and shall apply to insur-
     9  ance  policies  issued, amended, or renewed on or after January 1, 2024;
    10  provided, however, that the amendments to subdivision 9 of section 367-a
    11  of the social services law made by section fourteen of  this  act  shall
    12  not  affect  the expiration of such subdivision pursuant to section 4 of
    13  chapter 19 of the laws of 1998, as amended, and shall expire  therewith;
    14  and  provided,  further,  that  the  amendments  to section 364-j of the
    15  social services law made by section fifteen of this act shall not affect
    16  the repeal of such section  and  shall  be  deemed  repealed  therewith.
    17  Effective immediately, the addition, amendment and/or repeal of any rule
    18  or regulation necessary for the implementation of this act on its effec-
    19  tive  date  are  authorized  to  be made and completed on or before such
    20  date.
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