Bill Text: NY S00836 | 2023-2024 | General Assembly | Introduced
Bill Title: Provides for patient prescription pricing transparency; requires certain insurers or pharmacy benefit managers to furnish required cost, benefit and coverage data upon request of the insured, the insured's health care provider or an authorized third party.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced) 2023-02-13 - SUBSTITUTED BY A2200 [S00836 Detail]
Download: New_York-2023-S00836-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 836 2023-2024 Regular Sessions IN SENATE January 6, 2023 ___________ Introduced by Sen. BRESLIN -- read twice and ordered printed, and when printed to be committed to the Committee on Rules AN ACT to amend the insurance law and the public health law, in relation to patient prescription pricing transparency; and to repeal certain provisions of the insurance law related thereto The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Subsection 341-a of the insurance law, as added by a chap- 2 ter of the laws of 2022 amending the insurance law relating to enacting 3 the "patient Rx information and choice expansion act", as proposed in 4 legislative bills numbers S. 4620-C and A. 5411-D, is REPEALED. 5 § 2. Section 3217-a of the insurance law is amended by adding a new 6 subsection (g) to read as follows: 7 (g) (1) As used in this subsection: 8 (A) "Pharmacy benefit manager" shall have the meanings set forth in 9 section two hundred eighty-a of the public health law. 10 (B) "Cost-sharing information" means the amount an insured is required 11 to pay to receive a drug that is covered under the insured's insurance 12 policy. 13 (C) "Covered/coverage" means those health care services to which an 14 insured is entitled under the terms of the insurance policy. 15 (D) "Electronic health record" means a digital version of a patient's 16 paper chart and medical history that makes information available 17 instantly and securely to authorized users. 18 (E) "Electronic prescribing system" means a system that enables pres- 19 cribers to enter prescription information into a computer prescription 20 device and securely transmit the prescription to pharmacies using a 21 special software program and connectivity to a transmission network. 22 (F) "Electronic prescription" means an electronic prescription as 23 defined in section thirty-three hundred two of the public health law. EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD04034-01-3S. 836 2 1 (G) "Prescriber" means a health care provider licensed to prescribe 2 medication or medical devices in this state. 3 (H) "Real-time benefit tool" or "RTBT" means an electronic 4 prescription decision support tool that: (i) is capable of integrating 5 with prescribers' electronic prescribing system and, if feasible, elec- 6 tronic health record systems; and (ii) complies with the technical stan- 7 dards adopted by an American National Standards Institute (ANSI) accred- 8 ited standards development organization. 9 (I) "Authorized third party" shall include a third party legally 10 authorized under state or federal law subject to a Health Insurance 11 Portability and Accountability Act (HIPAA) business associate agreement. 12 (2) The provisions of this section shall not apply to any health plan 13 that exclusively serves individuals enrolled pursuant to a federal or 14 state insurance affordability program, including the medical assistance 15 program under title eleven of article five of the social services law, 16 child health plus under section twenty-five hundred eleven of the public 17 health law, the basic health program under section three hundred sixty- 18 nine-gg of the social services law, or a plan providing services under 19 title XVIII of the federal social security act. 20 (3) An insurer subject to this article or pharmacy benefit manager 21 shall, upon request of the insured, the insured's health care provider, 22 or an authorized third party on the insured's behalf, made to the insur- 23 er or pharmacy benefit manager, furnish the cost, benefit, and coverage 24 data required by this subsection to the insured, the insured's health 25 care provider, or the authorized third party and shall ensure that such 26 data is: (A) current no later than one business day after any change to 27 the cost, benefit, or coverage data is made; (B) provided through an 28 RTBT when the request is made by the insured's health care provider; and 29 (C) in a format that is easily accessible to the requestor. 30 (4) When providing the data required by paragraph three of this 31 subsection, the insurer or pharmacy benefit manager shall use estab- 32 lished industry content and transport standards published by: 33 (A) a standards developing organization accredited by the American 34 National Standards Institute (ANSI), including, the National Council for 35 Prescription Drug Programs (NCPDP), ASC X12, Health Level 7; or 36 (B) a relevant federal or state governing body, including the Center 37 for Medicare & Medicaid Services or the Office of the National Coordina- 38 tor for Health Information Technology; or 39 (C) another format deemed acceptable to the department which provides 40 the data prescribed in paragraph three of this subsection and in the 41 same timeliness as required by this section. 42 (5) A facsimile shall not be considered an acceptable electronic 43 format pursuant to this subsection. 44 (6) Upon a request made pursuant to paragraph three of this 45 subsection, the insurer or pharmacy benefit manager shall provide the 46 following data for any drug covered under the insured's insurance poli- 47 cy: 48 (A) insured-specific eligibility information; 49 (B) insured-specific prescription cost and benefit data, such as 50 applicable formulary, benefit, coverage and cost-sharing data for the 51 prescribed drug and clinically-appropriate alternatives, when appropri- 52 ate; 53 (C) insured-specific cost-sharing information that describes variance 54 in cost-sharing based on the pharmacy dispensing the prescribed drug or 55 its alternatives, and in relation to the insured's benefit; and 56 (D) applicable utilization management requirements.S. 836 3 1 (7) Any insurer or pharmacy benefit manager shall furnish the data as 2 required whether the request is made using the drug's unique billing 3 code, such as a National Drug Code or Healthcare Common Procedure Coding 4 System code or descriptive term. An insurer or pharmacy benefit manager 5 shall not deny or unreasonably delay processing a request. 6 (8) An insurer and pharmacy benefit manager shall not, except as may 7 be required or authorized by law, interfere with, prevent, or materially 8 discourage access, exchange, or use of the data as required; nor shall 9 an insurer or pharmacy benefit manager penalize a health care provider 10 for disclosing such information to an insured or legally prescribing, 11 administering, or ordering a lower cost clinically appropriate alterna- 12 tive. 13 (9) Nothing in this subsection shall be construed to limit access to 14 the most up-to-date insured-specific eligibility or insured-specific 15 prescription cost and benefit data by the insurer or pharmacy benefit 16 manager. 17 (10) Nothing in this subsection shall interfere with insured choice 18 and a health care provider's ability to convey the full range of 19 prescription drug cost options to an insured. Insurers and pharmacy 20 benefit managers shall not restrict a health care provider from communi- 21 cating to the insured prescription cost options. 22 § 3. Section 4324 of the insurance law is amended by adding a new 23 subsection (g) to read as follows: 24 (g) (1) As used in this subsection: 25 (A) "Pharmacy benefit manager" shall have the meaning set forth in 26 section two hundred eighty-a of the public health law. 27 (B) "Cost-sharing information" means the amount a subscriber is 28 required to pay to receive a drug that is covered under the subscriber's 29 insurance contract. 30 (C) "Covered/coverage" means those health care services to which a 31 subscriber is entitled under the terms of the insurance contract. 32 (D) "Electronic health record" means a digital version of a patient's 33 paper chart and medical history that makes information available 34 instantly and securely to authorized users. 35 (E) "Electronic prescribing system" means a system that enables pres- 36 cribers to enter prescription information into a computer prescription 37 device and securely transmit the prescription to pharmacies using a 38 special software program and connectivity to a transmission network. 39 (F) "Electronic prescription" shall have the meaning set forth in 40 section thirty-three hundred two of the public health law. 41 (G) "Prescriber" means a health care provider licensed to prescribe 42 medication or medical devices in this state. 43 (H) "Real-time benefit tool" or "RTBT" means an electronic 44 prescription decision support tool that: (i) is capable of integrating 45 with prescribers' electronic prescribing system and, if feasible, elec- 46 tronic health record systems; and (ii) complies with the technical stan- 47 dards adopted by an American National Standards Institute (ANSI) accred- 48 ited standards development organization. 49 (I) "Authorized third party" shall include a third party legally 50 authorized under state or federal law subject to a Health Insurance 51 Portability and Accountability Act (HIPAA) business associate agreement. 52 (2) The provisions of this section shall not apply to any health plan 53 that exclusively serves individuals enrolled pursuant to a federal or 54 state insurance affordability program, including the medical assistance 55 program under title eleven of article five of the social services law, 56 child health plus under section twenty-five hundred eleven of the publicS. 836 4 1 health law, the basic health program under section three hundred sixty- 2 nine-gg of the social services law, or a plan providing services under 3 title XVIII of the federal social security act. 4 (3) A health service, hospital service, or medical expense indemnity 5 corporation subject to this article or pharmacy benefit manager shall, 6 upon request of the subscriber, the subscriber's health care provider, 7 or an authorized third party on the subscriber's behalf, made to the 8 health service, hospital service, or medical expense indemnity corpo- 9 ration or pharmacy benefit manager, furnish the cost, benefit, and 10 coverage data required by this subsection to the subscriber, the 11 subscriber's health care provider, or the authorized third party and 12 shall ensure that such data is: (A) current no later than one business 13 day after any change to the cost, benefit, or coverage data is made; (B) 14 provided through a RTBT when the request is made by the subscriber's 15 health care provider; and (C) in a format that is easily accessible to 16 the requestor. 17 (4) When providing the data required by paragraph three of this 18 subsection, the health service, hospital service, or medical expense 19 indemnity corporation or pharmacy benefit manager shall use established 20 industry content and transport standards published by: 21 (A) a standards developing organization accredited by the American 22 National Standards Institute (ANSI), including, the National Council for 23 Prescription Drug Programs (NCPDP), ASC X12, Health Level 7; or 24 (B) a relevant federal or state governing body, including the Center 25 for Medicare & Medicaid Services or the Office of the National Coordina- 26 tor for Health Information Technology. 27 (C) another format deemed acceptable to the department which provides 28 the data prescribed in paragraph three of this subsection and in the 29 same timeliness as required by this section. 30 (5) A facsimile shall not be considered an acceptable electronic 31 format pursuant to this subsection. 32 (6) Upon a request made pursuant to paragraph three of this 33 subsection, the health service, hospital service, or medical expense 34 indemnity corporation or pharmacy benefit manager shall provide the 35 following data for any drug covered under the subscriber's insurance 36 contract: 37 (A) subscriber-specific eligibility information; 38 (B) subscriber-specific prescription cost and benefit data, such as 39 applicable formulary, benefit, coverage, and cost-sharing data for the 40 prescribed drug and clinically-appropriate alternatives, when appropri- 41 ate; 42 (C) subscriber-specific cost-sharing information that describes vari- 43 ance in cost-sharing based on the pharmacy dispensing the prescribed 44 drug or its alternatives, and in relation to the insured's benefit; and 45 (D) applicable utilization management requirements. 46 (7) A health service, hospital service, or medical expense indemnity 47 corporation or pharmacy benefit manager shall furnish the data as 48 required whether the request is made using the drug's unique billing 49 code, such as a National Drug Code or Healthcare Common Procedure Coding 50 System code or descriptive term. A health service, hospital service, or 51 medical expense indemnity corporation or pharmacy benefit manager shall 52 not deny or unreasonably delay processing a request. 53 (8) A health service, hospital service, or medical expense indemnity 54 corporation and pharmacy benefit manager shall not, except as may be 55 required or authorized by law, interfere with, prevent, or materially 56 discourage access, exchange, or use of the data as required; nor shall aS. 836 5 1 health service, hospital service, or medical expense indemnity corpo- 2 ration or pharmacy benefit manager penalize a health care provider for 3 disclosing such information to a subscriber or legally prescribing, 4 administering, or ordering a lower cost, clinically appropriate alterna- 5 tive. 6 (9) Nothing in this subsection shall be construed to limit access to 7 the most up-to-date subscriber-specific eligibility or subscriber-spe- 8 cific prescription cost and benefit data by the health service, hospital 9 service, or medical expense indemnity corporation or pharmacy benefit 10 manager. 11 (10) Nothing in this subsection shall interfere with subscriber choice 12 and a health care provider's ability to convey the full range of 13 prescription drug cost options to a subscriber. Health service, hospital 14 service, or medical expense indemnity corporations and pharmacy benefit 15 managers shall not restrict a health care provider from communicating to 16 the subscriber prescription cost options. 17 § 4. Section 4408 of the public health law is amended by adding a new 18 subdivision 8 to read as follows: 19 8. (a) As used in this subdivision: 20 (i) "Pharmacy benefit manager" shall have the meaning set forth in 21 section two hundred eighty-a of this chapter. 22 (ii) "Cost-sharing information" means the amount a subscriber is 23 required to pay to receive a drug that is covered under the subscriber's 24 insurance contract. 25 (iii) "Covered/coverage" means those health care services to which a 26 subscriber is entitled under the terms of the subscriber contract. 27 (iv) "Electronic health record" means a digital version of a patient's 28 paper chart and medical history that makes information available 29 instantly and securely to authorized users. 30 (v) "Electronic prescribing system" means a system that enables pres- 31 cribers to enter prescription information into a computer prescription 32 device and securely transmit the prescription to pharmacies using a 33 special software program and connectivity to a transmission network. 34 (vi) "Electronic prescription" shall have the meaning set forth in 35 section thirty-three hundred two of this chapter. 36 (vii) "Prescriber" means a health care provider licensed to prescribe 37 medication or medical devices in this state. 38 (viii) "Real-time benefit tool" or "RTBT" means an electronic 39 prescription decision support tool that: (1) is capable of integrating 40 with prescribers' electronic prescribing system and, if feasible, elec- 41 tronic health record systems; and (2) complies with the technical stand- 42 ards adopted by an American National Standards Institute (ANSI) accred- 43 ited standards development organization. 44 (ix) "Authorized third party" shall include a third party legally 45 authorized under state or federal law subject to a Health Insurance 46 Portability and Accountability Act (HIPAA) business associate agreement. 47 (b) The provisions of this section shall not apply to any health plan 48 that exclusively serves individuals enrolled pursuant to a federal or 49 state insurance affordability program, including the medical assistance 50 program under title eleven of article five of the social services law, 51 child health plus under section twenty-five hundred eleven of this chap- 52 ter, the basic health program under section three hundred sixty-nine-gg 53 of the social services law, or a plan providing services under title 54 XVIII of the federal social security act. 55 (c) A health maintenance organization or pharmacy benefit manager 56 shall, upon request of the subscriber, the subscriber's health careS. 836 6 1 provider, or an authorized third party on the subscriber's behalf, made 2 to the health maintenance organization or pharmacy benefit manager, 3 furnish the cost, benefit, and coverage data required by this subdivi- 4 sion to the subscriber, the subscriber's health care provider, or the 5 authorized third party and shall ensure that such data is: (i) current 6 no later than one business day after any change to the cost, benefit, or 7 coverage data is made; (ii) provided through a RTBT when the request is 8 made by the subscriber's health care provider; and (iii) in a format 9 that is easily accessible to the requestor. 10 (d) When providing the data required by paragraph (c) of this subdivi- 11 sion, the health maintenance organization or pharmacy benefit manager 12 shall use established industry content and transport standards published 13 by: 14 (i) a standards developing organization accredited by the American 15 National Standards Institute (ANSI), including, the National Council for 16 Prescription Drug Programs (NCPDP), ASC X12, Health Level 7; or 17 (ii) a relevant federal or state governing body, including the Center 18 for Medicare & Medicaid Services or the Office of the National Coordina- 19 tor for Health Information Technology. 20 (iii) another format deemed acceptable to the department which 21 provides the data prescribed in paragraph (c) of this subdivision and in 22 the same timeliness as required by this section. 23 (e) A facsimile shall not be considered an acceptable electronic 24 format pursuant to this subdivision. 25 (f) Upon a request made pursuant to paragraph (c) of this subdivision, 26 the health maintenance organization or pharmacy benefit manager shall 27 provide the following data for any drug covered under the subscriber's 28 subscriber contract: 29 (i) subscriber-specific eligibility information; 30 (ii) subscriber-specific prescription cost and benefit data, such as 31 applicable formulary, benefit, coverage, and cost-sharing data for the 32 prescribed drug and clinically-appropriate alternatives, when appropri- 33 ate; 34 (iii) subscriber-specific cost-sharing information that describes 35 variance in cost-sharing based on the pharmacy dispensing the prescribed 36 drug or its alternatives, and in relation to the insured's benefit; and 37 (iv) applicable utilization management requirements. 38 (g) A health maintenance organization or pharmacy benefit manager 39 shall furnish the data as required whether the request is made using the 40 drug's unique billing code, such as a National Drug Code or Healthcare 41 Common Procedure Coding System code or descriptive term. A health main- 42 tenance organization or pharmacy benefit manager shall not deny or 43 unreasonably delay processing a request. 44 (h) A health maintenance organization and pharmacy benefit manager 45 shall not, except as may be required or authorized by law, interfere 46 with, prevent, or materially discourage access, exchange, or use of the 47 data as required; nor shall a health maintenance organization or pharma- 48 cy benefit manager penalize a health care provider for disclosing such 49 information to a subscriber or legally prescribing, administering, or 50 ordering a lower cost, clinically appropriate alternative. 51 (i) Nothing in this subdivision shall be construed to limit access to 52 the most up-to-date subscriber-specific eligibility or subscriber-spe- 53 cific prescription cost and benefit data by the health maintenance 54 organization or pharmacy benefit manager. 55 (j) Nothing in this subdivision shall interfere with subscriber choice 56 and a health care provider's ability to convey the full range ofS. 836 7 1 prescription drug cost options to a subscriber. Health maintenance 2 organizations and pharmacy benefit managers shall not restrict a health 3 care provider from communicating to the subscriber prescription cost 4 options. 5 § 5. Severability. If any provision of this act, or any application of 6 any provision of this act, is held to be invalid, or to violate or be 7 inconsistent with any federal law or regulation, that shall not affect 8 the validity or effectiveness of any other provision of this act, or of 9 any other application of any provision of this act, which can be given 10 effect without that provision or application; and to that end, the 11 provisions and applications of this act are severable. 12 § 6. This act shall take effect on the same date and in the same 13 manner as a chapter of the laws of 2022 amending the insurance law 14 relating to enacting the "patient Rx information and choice expansion 15 act", as proposed in legislative bills numbers S. 4620-C and A. 5411-D, 16 takes effect.
