NY Pub Health L § 280-A (2021)
2021 New York Laws PBH - Public Health Article 2-A - Prescription Drugs Title 2 - Prescription Drugs; Various Provisions 280-A - Pharmacy Benefit Managers.

§  280-a.  Pharmacy  benefit managers. 1. Definitions. As used in this section, the following terms shall have the following meanings:  (a) "Pharmacy benefit manager" means an  entity  that  contracts  with pharmacies  or  pharmacy  contracting agents on behalf of a health plan, state agency, insurer, managed care organization, or other  third  party payor to provide pharmacy health benefit services or administration.  (b)  "Maximum  allowable  cost  price"  means  a maximum reimbursement amount  set  by  the  pharmacy  benefit  manager   for   therapeutically equivalent multiple source generic drugs.   2. A pharmacy benefit manager shall, with respect to contracts between a  pharmacy benefit manager and a pharmacy or, alternatively, a pharmacy benefit manager and a pharmacy's contracting agent, such as  a  pharmacy services  administrative  organization,  include a reasonable process to appeal, investigate and resolve disputes regarding multi-source  generic drug   pricing.   The   appeals  process  shall  include  the  following provisions:  (a) the  right  to  appeal  by  the  pharmacy  and/or  the  pharmacy's contracting  agent shall be limited to thirty days following the initial claim submitted for payment;  (b) a telephone number through which a network  pharmacy  may  contact the  pharmacy benefit manager for the purpose of filing an appeal and an electronic mail  address  of  the  individual  who  is  responsible  for processing appeals;  (c) the pharmacy benefit manager shall send an electronic mail message acknowledging  receipt of the appeal. The pharmacy benefit manager shall respond in an electronic message to the pharmacy and/or  the  pharmacy's contracting   agent   filing  the  appeal  within  seven  business  days indicating its determination. If the appeal is determined to  be  valid, the  maximum  allowable  cost  for  the  drug  shall be adjusted for the appealing pharmacy effective as of the date of the  original  claim  for payment.  The  pharmacy  benefit  manager  shall  require  the appealing pharmacy to reverse and rebill the claim in question in order to  obtain the corrected reimbursement;  (d)  if  an  update  to  the  maximum allowable cost is warranted, the pharmacy benefit manager or covered  entity  shall  adjust  the  maximum allowable  cost  of  the  drug  effective  for  all  similarly  situated pharmacies in its network in the  state  on  the  date  the  appeal  was determined to be valid; and  (e)  if  an  appeal  is  denied,  the  pharmacy  benefit manager shall identify the national drug code of a therapeutically equivalent drug, as determined  by  the  federal  Food  and  Drug  Administration,  that  is available  for  purchase  by  pharmacies  in this state from wholesalers registered pursuant to subdivision four of section  sixty-eight  hundred eight of the education law at a price which is equal to or less than the maximum  allowable  cost  for  that  drug  as determined by the pharmacy benefit manager.   3. No pharmacy  benefit  manager  shall,  with  respect  to  contracts between  such pharmacy benefit manager and a pharmacy or, alternatively, such pharmacy benefit manager and a pharmacy's contracting  agent,  such as a pharmacy services administrative organization:  (a)  prohibit  or penalize a pharmacist or pharmacy from disclosing to an  individual  purchasing   a   prescription   medication   information regarding:  (1) the cost of the prescription medication to the individual, or  (2)  the  availability  of  any therapeutically equivalent alternative medications  or  alternative  methods  of  purchasing  the  prescription medication, including but not limited to, paying a cash price; or  (b)  charge or collect from an individual a copayment that exceeds the total submitted charges by the pharmacy for which the pharmacy is  paid. If  an  individual  pays  a  copayment,  the  pharmacy  shall retain the adjudicated costs and the pharmacy benefit manager shall not  redact  or recoup the adjudicated cost.   4.  Any  provision  of a contract that violates the provisions of this section shall be deemed to be void and unenforceable.