Bill Text: NY A09267 | 2021-2022 | General Assembly | Introduced
Bill Title: Requires a utilization review agent to follow certain rules when establishing a step therapy protocol; requires that the protocol accepts any attestation submitted by the insured's health care professional stating that a required drug has failed as prima facie evidence that the required drug has failed.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Introduced - Dead) 2022-02-09 - referred to insurance [A09267 Detail]
Download: New_York-2021-A09267-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 9267 IN ASSEMBLY February 9, 2022 ___________ Introduced by M. of A. McDONALD -- read once and referred to the Commit- tee on Insurance AN ACT to amend the insurance law and the public health law, in relation to requiring a utilization review agent to follow certain rules when establishing a step therapy protocol The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Subsection (a) of section 4902 of the insurance law is 2 amended by adding two new paragraphs 14 and 15 to read as follows: 3 (14) When establishing a step therapy protocol, a utilization review 4 agent shall ensure that the protocol cannot: 5 (i) require a prescription drug that has not been approved by the 6 United States Food and Drug Administration for the medical condition 7 being treated; 8 (ii) require an insured to try and fail on more than one drug before 9 providing coverage to the insured for the prescribed drug; 10 (iii) require the use of a step therapy-required drug for longer than 11 thirty days; 12 (iv) be imposed on an insured if the insured has taken the prescribed 13 drug covered by the plan within the past three hundred sixty-five days; 14 (v) require a newly enrolled insured to repeat step therapy for a 15 prescribed drug where that insured already completed step therapy for 16 that drug under a prior plan; and 17 (vi) be imposed on an insured for a prescribed drug that was previous- 18 ly approved for coverage by a plan for a specific medical condition 19 after the insured's plan implements a formulary change that impacts the 20 formulary status of the prescribed drug. 21 (15) When establishing a step therapy protocol, a utilization review 22 agent shall ensure that the protocol accepts any attestation submitted 23 by the insured's health care professional as defined in section four 24 thousand nine hundred of this title stating that a required drug has 25 failed as prima facie evidence that the required drug has failed. EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD14433-01-2A. 9267 2 1 § 2. Subsections (c-3) and (g) of section 4903 of the insurance law, 2 subsection (c-3) as added and subsection (g) as amended by chapter 512 3 of the laws of 2016, are amended to read as follows: 4 (c-3) Upon a determination that the step therapy protocol should be 5 overridden, the health plan shall authorize immediate coverage for the 6 prescription drug prescribed by the insured's treating health care 7 professional. Any approval of a step therapy protocol override determi- 8 nation request shall be honored until the later of twelve months follow- 9 ing the date of the approval or renewal of the plan. 10 (g) Failure by the utilization review agent to make a determination 11 within the time periods prescribed in this section shall be deemed to be 12 an adverse determination subject to appeal pursuant to section four 13 thousand nine hundred four of this title, provided, however, that fail- 14 ure to meet such time periods for a step therapy protocol as defined in 15 subsection (g-9) of section forty-nine hundred of this title or a step 16 therapy protocol override determination pursuant to subsections (c-1), 17 (c-2) and (c-3) of this section shall be deemed to be an override of the 18 step therapy protocol. A utilization review agent's failure to comply 19 with any of the step therapy protocol requirements required in 20 subsections fourteen and fifteen of section four thousand nine hundred 21 two of this title shall be considered a basis for granting an override 22 of the step therapy protocol. 23 § 3. Section 4902 of the public health law is amended by adding two 24 new subdivisions 5 and 6 to read as follows: 25 5. When establishing a step therapy protocol, a utilization review 26 agent shall ensure that the protocol cannot: 27 (a) require a prescription drug that has not been approved by the 28 United States Food and Drug Administration for the medical condition 29 being treated; 30 (b) require an enrollee to try and fail on more than one drug before 31 providing coverage to the insured for the prescribed drug; 32 (c) require the use of a step therapy-required drug for longer than 33 thirty days; 34 (d) be imposed on an enrollee if the enrollee has taken the prescribed 35 drug covered by the plan within the past three hundred sixty-five days; 36 (f) require a newly enrolled enrollee to repeat step therapy for a 37 prescribed drug where that enrollee already completed step therapy for 38 that drug under a prior plan; and 39 (g) be imposed on an enrollee for a prescribed drug that was previous- 40 ly approved for coverage by a plan for a specific medical condition 41 after the enrollee's plan implements a formulary change that impacts the 42 formulary status of the prescribed drug. 43 6. When establishing a step therapy protocol, a utilization review 44 agent shall ensure that the protocol accepts any attestation submitted 45 by the enrollee's health care professional as defined in section forty- 46 nine hundred of this title stating that a required drug has failed as 47 prima facie evidence that the required drug has failed. 48 § 4. Subdivisions 3-c and 7 of section 4903 of the public health law, 49 subdivision 3-c as added and subdivision 7 as amended by chapter 512 of 50 the laws of 2016, are amended to read as follows: 51 3-c. Upon a determination that the step therapy protocol should be 52 overridden, the health plan shall authorize immediate coverage for the 53 prescription drug or drugs prescribed by the enrollee's treating health 54 care professional. Any approval of a step therapy protocol override 55 determination request shall be honored until the later of twelve months 56 following the date of the approval or renewal of the plan.A. 9267 3 1 7. Failure by the utilization review agent to make a determination 2 within the time periods prescribed in this section shall be deemed to be 3 an adverse determination subject to appeal pursuant to section forty- 4 nine hundred four of this title, provided, however, that failure to meet 5 such time periods for a step therapy protocol as defined in subdivision 6 seven-f-three of section forty-nine hundred of this title or a step 7 therapy protocol override determination pursuant to subdivisions 8 three-a, three-b and three-c of this section shall be deemed to be an 9 override of the step therapy protocol. A utilization review agent's 10 failure to comply with any of the step therapy protocol requirements 11 required in subdivisions five and six of section forty-nine hundred two 12 of this title shall be considered a basis for granting an override of 13 the step therapy protocol. 14 § 5. This act shall take effect immediately.
