NY Ins L § 4329 (2021)
2021 New York Laws ISC - Insurance Article 43 - Non-Profit Medical and Dental Indemnity, or Health and Hospital Service Corporations 4329 - Prescription Drug Coverage.

§  4329.  Prescription drug coverage. (a) Every corporation subject to the provisions of this article that  issues  a  contract  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  contract  issued  by  a  corporation  subject  to the provisions of this article that provides coverage for prescription drugs shall include in the contract 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,  a  corporation  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)  A  corporation  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 contract.  (B)  A  corporation 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) A corporation 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)  A  corporation  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  is  not covered by the contract.  (B) A corporation 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)   A   corporation  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) A corporation 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 corporation  to treat the insured.  (5)  (A)  If  a  corporation  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 and article forty-nine of the public health law.  (B) An external  appeal  agent  shall  make  a  determination  on  the external appeal and notify the corporation, 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 corporation,  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 corporation, 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 corporation, 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 and 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  corporation  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 corporation's denial  of a  standard  exception  request  under paragraph two of this subsection, then  the  corporation  shall  provide  coverage  of  the  non-formulary prescription  drug  for  the  duration  of  the  prescription, including refills. If an external appeal agent overturns the corporation's  denial of  an  expedited  exception  request  under  paragraph  three  of  this subsection,  then  the  corporation  shall  provide  coverage   of   the non-formulary   prescription  drug  for  the  duration  of  the  exigent circumstances.