Bill Text: NY S03419 | 2015-2016 | General Assembly | Introduced

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Relates to expedited utilization review of prescription drugs.

Spectrum: Slight Partisan Bill (Democrat 11-7)

Status: (Passed) 2016-12-31 - SIGNED CHAP.512 [S03419 Detail]

Download: New_York-2015-S03419-Introduced.html

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                           S T A T E   O F   N E W   Y O R K
       ________________________________________________________________________
                                         3419
                              2015-2016 Regular Sessions
                                   I N  S E N A T E
                                   February 9, 2015
                                      ___________
       Introduced  by  Sens.  YOUNG, BRESLIN, GOLDEN, LANZA, MARCHIONE, PARKER,
         VALESKY -- read twice and ordered printed,  and  when  printed  to  be
         committed to the Committee on Insurance
       AN ACT to amend the insurance law, in relation to the regulation of step
         therapy and first fail policies
         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 article 33  to
    2  read as follows:
    3                                 ARTICLE 33
    4                       REGULATION OF STEP THERAPY AND
    5                             FIRST FAIL POLICIES
    6  SECTION 3301. DEFINITIONS.
    7          3302. PRESCRIPTION DRUG RESTRICTION OVERRIDES.
    8    S 3301. DEFINITIONS. AS USED IN THIS ARTICLE:
    9    (A)  "INSURER"  SHALL MEAN ANY PERSON OR ENTITY WHO OFFERS A POLICY OF
   10  ACCIDENT AND/OR HEALTH INSURANCE PURSUANT TO SECTION THREE THOUSAND  TWO
   11  HUNDRED SIXTEEN, THREE THOUSAND TWO HUNDRED TWENTY-ONE, OR FOUR THOUSAND
   12  THREE  HUNDRED THREE OF THIS CHAPTER OR ARTICLE FORTY-FOUR OF THE PUBLIC
   13  HEALTH LAW.
   14    (B) "PHARMACY BENEFIT MANAGEMENT" OR  "PBM"  SHALL  MEAN  THE  SERVICE
   15  PROVIDED  TO  AN  INSURER, DIRECTLY OR THROUGH ANOTHER ENTITY; INCLUDING
   16  THE PROCUREMENT  OF  PRESCRIPTION  DRUGS  TO  BE  DISPENSED  TO  COVERED
   17  PERSONS,  OR THE ADMINISTRATION OR MANAGEMENT OF PRESCRIPTION DRUG BENE-
   18  FITS INCLUDING, BUT NOT LIMITED TO, ANY OF THE FOLLOWING:
   19    (1) A MAIL ORDER PHARMACY;
   20    (2) CLAIMS PROCESSING, RETAIL NETWORK MANAGEMENT AND PAYMENT OF CLAIMS
   21  TO PHARMACIES FOR DISPENSING PRESCRIPTION DRUGS;
   22    (3) CLINICAL OR OTHER FORMULARY, OR PREFERRED DRUG LIST DEVELOPMENT OR
   23  MANAGEMENT;
        EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                             [ ] is old law to be omitted.
                                                                  LBD03838-01-5
       S. 3419                             2
    1    (4) NEGOTIATION  OR  ADMINISTRATION  OF  REBATES,  DISCOUNTS,  PAYMENT
    2  DIFFERENTIALS  OR  OTHER  INCENTIVES  FOR  THE  INCLUSION  OF PARTICULAR
    3  PRESCRIPTION DRUGS IN A PARTICULAR CATEGORY OR TO PROMOTE  THE  PURCHASE
    4  OF PARTICULAR PRESCRIPTION DRUGS;
    5    (5)  PATIENT  COMPLIANCE, THERAPEUTIC INTERVENTION AND GENERIC SUBSTI-
    6  TUTION PROGRAMS; AND
    7    (6) DISEASE MANAGEMENT.
    8    S 3302. PRESCRIPTION DRUG RESTRICTION OVERRIDES. (A) WHEN  MEDICATIONS
    9  FOR  THE TREATMENT OF ANY MEDICAL CONDITION ARE RESTRICTED FOR USE BY AN
   10  INSURER OR PBM BY A STEP THERAPY OR FAIL FIRST  PROTOCOL,  A  PRESCRIBER
   11  SHALL HAVE ACCESS TO A CLEAR AND CONVENIENT PROCESS AT NO CHARGE TO SUCH
   12  PRESCRIBER AND/OR PATIENT TO OVERRIDE SUCH RESTRICTIONS FROM THE INSURER
   13  AND MAY EXPEDITIOUSLY OVERRIDE SUCH RESTRICTION IF:
   14    (1)  SUCH  PRESCRIBER,  IN  HIS OR HER PROFESSIONAL JUDGMENT, BELIEVES
   15  THAT THE PREFERRED TREATMENT BY THE INSURER OR THE PBM HAS BEEN INEFFEC-
   16  TIVE IN THE TREATMENT OF THE COVERED PERSON'S DISEASE OR MEDICAL  CONDI-
   17  TION; OR
   18    (2)  BASED  ON  SOUND  CLINICAL  EVIDENCE  AND  MEDICAL AND SCIENTIFIC
   19  EVIDENCE:
   20    (A) SUCH PRESCRIBER, IN HIS OR  HER  PROFESSIONAL  JUDGMENT,  BELIEVES
   21  THAT  THE PREFERRED TREATMENT IS EXPECTED TO BE INEFFECTIVE BASED ON THE
   22  KNOWN RELEVANT PHYSICAL OR MENTAL CHARACTERISTICS OF THE COVERED  PERSON
   23  AND KNOWN CHARACTERISTICS OF THE DRUG REGIMEN, AND IS LIKELY TO BE INEF-
   24  FECTIVE  OR ADVERSELY AFFECT THE DRUG'S EFFECTIVENESS OR PATIENT COMPLI-
   25  ANCE; OR
   26    (B) SUCH PRESCRIBER, IN HIS OR  HER  PROFESSIONAL  JUDGMENT,  BELIEVES
   27  THAT THE PREFERRED TREATMENT HAS CAUSED OR IS LIKELY TO CAUSE AN ADVERSE
   28  REACTION OR OTHER HARM TO THE COVERED PERSON.
   29    (B)  THE DURATION OF ANY STEP THERAPY OR FAIL FIRST PROTOCOL SHALL NOT
   30  BE LONGER THAN EITHER (1) THE PERIOD DEEMED NECESSARY BY THE PRESCRIBING
   31  PHYSICIAN OR HEALTH CARE PROFESSIONAL TO DETERMINE THE TREATMENT'S CLIN-
   32  ICAL EFFECTIVENESS, OR (2) A PERIOD OF THIRTY DAYS.
   33    (C) NOTHING IN THIS SECTION SHALL REQUIRE COVERAGE FOR  AN  ADDITIONAL
   34  CONDITION NOT ALREADY COVERED BY THE POLICY OR CONTRACT, OR WHICH IS NOT
   35  OTHERWISE COVERED BY LAW.
   36    S 2. This act shall take effect on the one hundred twentieth day after
   37  it shall have become a law.