NY Ins L § 3242 (2021)
2021 New York Laws ISC - Insurance Article 32 - Insurance Contracts - Life, Accident and Health, Annuities 3242 - Prescription Drug Coverage.

§ 3242. Prescription drug coverage. (a) Every insurer that delivers or issues  for  delivery  in this state a policy that provides coverage for prescription  drugs  shall,  with  respect  to  the  prescription   drug coverage,  publish  an  up-to-date,  accurate,  and complete list of all covered prescription drugs on its formulary  drug  list,  including  any tiering structure that it has adopted and any restrictions on the manner in which a prescription drug may be obtained, in a manner that is easily accessible to insureds and prospective insureds. The formulary drug list shall  clearly  identify  the  preventive  prescription  drugs  that are available  without  annual   deductibles   or   coinsurance,   including co-payments.  (b)  (1)  Every  policy delivered or issued for delivery in this state that provides coverage for  prescription  drugs  shall  include  in  the policy  a process that allows an insured, the insured's designee, or the insured's prescribing  health  care  provider  to  request  a  formulary exception.  With  respect to the process for such a formulary exception, an insurer shall follow the process and procedures specified in  article forty-nine  of  this chapter and article forty-nine of the public health law, except as otherwise provided in paragraphs  two,  three,  four  and five of this subsection.  (2)  (A) An insurer shall have a process for an insured, the insured's designee, or the insured's prescribing health care provider to request a standard review  that  is  not  based  on  exigent  circumstances  of  a formulary  exception  for a prescription drug that is not covered by the policy.  (B) An insurer shall make a  determination  on  a  standard  exception request  that  is  not  based  on  exigent  circumstances and notify the insured or the insured's designee and the insured's  prescribing  health care  provider  by telephone of its coverage determination no later than seventy-two hours following receipt of the request.  (C) An insurer that grants a standard exception request  that  is  not based   on   exigent   circumstances   shall  provide  coverage  of  the non-formulary prescription drug for the duration  of  the  prescription, including refills.  (D)  For the purpose of this subsection, "exigent circumstances" means when an insured is suffering from a health condition that may  seriously jeopardize  the  insured's  life,  health,  or ability to regain maximum function or when an insured is undergoing a current course of  treatment using a non-formulary prescription drug.  (3)  (A) An insurer shall have a process for an insured, the insured's designee, or the insured's prescribing health care provider  to  request an  expedited  review  based  on  exigent  circumstances  of a formulary exception for a prescription drug that is not covered by the policy.  (B) An insurer shall make  a  determination  on  an  expedited  review request  based  on  exigent  circumstances and notify the insured or the insured's designee and the insured's prescribing health care provider by telephone of its coverage determination no later than twenty-four  hours following receipt of the request.  (C) An insurer that grants an exception based on exigent circumstances shall  provide  coverage  of the non-formulary prescription drug for the duration of the exigent circumstances.  (4) An insurer that denies an exception request under paragraph two or three  of  this  subsection  shall  provide  written   notice   of   its determination to the insured or the insured's designee and the insured's prescribing  health  care provider within three business days of receipt of the exception request. The written notice shall be considered a final adverse determination under section four thousand nine hundred  four  of this  chapter  or  section four thousand nine hundred four of the public  health law. Written notice shall also  include  the  name  or  names  of clinically  appropriate  prescription  drugs  covered  by the insurer to treat the insured.  (5)  (A)  If  an  insurer  denies  a  request  for  an exception under paragraph two or three of this subsection, the  insured,  the  insured's designee,  or  the insured's prescribing health care provider shall have the right to request that such denial be reviewed by an external  appeal agent  certified by the superintendent pursuant to section four thousand nine  hundred  eleven  of  this  chapter  in  accordance  with   article forty-nine  of  this  chapter or article forty-nine of the public health law.  (B) An external  appeal  agent  shall  make  a  determination  on  the external  appeal  and  notify  the insurer, the insured or the insured's designee,  and  the  insured's  prescribing  health  care  provider   by telephone of its determination no later than seventy-two hours following the  external  appeal  agent's  receipt  of the request, if the original request was a standard exception request under  paragraph  two  of  this subsection.  The  external  appeal  agent  shall notify the insurer, the insured or the insured's designee, and the insured's prescribing  health care provider in writing of the external appeal determination within two business days of rendering such determination.  (C)  An  external  appeal  agent  shall  make  a  determination on the external appeal and notify the insurer, the  insured  or  the  insured's designee,   and  the  insured's  prescribing  health  care  provider  by telephone of its determination no later than twenty-four hours following the external appeal agent's receipt of  the  request,  if  the  original request was an expedited exception request under paragraph three of this subsection  and  the  insured's prescribing health care provider attests that exigent circumstances exist. The external appeal agent shall notify the insurer, the insured or the insured's designee,  and  the  insured's prescribing  health  care  provider  in  writing  of the external appeal determination within seventy-two hours of the  external  appeal  agent's receipt of the external appeal.  (D)  An external appeal agent shall make a determination in accordance with subparagraph (A) of paragraph four of  subsection  (b)  of  section four  thousand nine hundred fourteen of this chapter or subparagraph (A) of paragraph (d) of  subdivision  two  of  section  four  thousand  nine hundred  fourteen of the public health law. When making a determination, the  external  appeal  agent  shall  consider  whether   the   formulary prescription   drug   covered  by  the  insurer  will  be  or  has  been ineffective, would not be as effective as the non-formulary prescription drug, or would have adverse effects.  (E) If an external appeal agent overturns the insurer's  denial  of  a standard  exception request under paragraph two of this subsection, then the insurer shall provide coverage  of  the  non-formulary  prescription drug  for  the  duration  of  the prescription, including refills. If an external appeal agent overturns the insurer's  denial  of  an  expedited exception  request  under  paragraph  three of this subsection, then the insurer shall provide coverage of the  non-formulary  prescription  drug for the duration of the exigent circumstances.