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. LBD10957-02-3A. 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 theA. 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 drugA. 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 theA. 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 byA. 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 theA. 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.
