2023 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.
* (c) (1) Except as otherwise provided  in  paragraph  three  of  this
subsection, a corporation shall not:
(A) remove a prescription drug from a formulary;
(B)  move  a  prescription  drug  to  a tier with a larger deductible,
copayment, or coinsurance if the formulary includes two or more tiers of

benefits providing for different deductibles, copayments or  coinsurance
applicable to the prescription drugs in each tier; or
(C)  add utilization management restrictions to a prescription drug on
a formulary, unless such  changes  occur  at  the  time  of  enrollment,
issuance or renewal of coverage.
(2)  Prohibitions  provided  in paragraph one of this subsection shall
apply beginning on the date on which a plan year begins and through  the
end of such plan year.
(3) (A) A corporation with a formulary that includes two or more tiers
of   benefits   providing   for  different  deductibles,  copayments  or
coinsurance applicable to prescription drugs in each  tier  may  move  a
prescription  drug  to  a  tier  with  a larger deductible, copayment or
coinsurance  if  an  AB-rated  generic  equivalent  or   interchangeable
biological  product for such prescription drug is added to the formulary
at the same time.
(B) A corporation may remove a prescription drug from a  formulary  if
the   federal   Food   and  Drug  Administration  determines  that  such
prescription drug should be  removed  from  the  market,  including  new
utilization  management restrictions issued pursuant to federal Food and
Drug Administration safety concerns.
(C) A corporation with a formulary that includes two or more tiers  of
benefits  providing  for different copayments applicable to prescription
drugs may move a prescription drug to a tier  with  a  larger  copayment
during  the  plan  year,  provided  the  change  is not applicable to an
insured who is already receiving such  prescription  drug  or  has  been
diagnosed with or presented with a condition on or prior to the start of
the  plan  year  that  is  treated  by  such  prescription  drug or is a
prescription drug that is or would be part of  the  insured's  treatment
regimen for such condition.
(4)  A  corporation  shall provide notice to insureds of the intent to
remove a  prescription  drug  from  a  formulary  or  alter  deductible,
copayment  or coinsurance requirements in the upcoming plan year, ninety
days prior to the start of the  plan  year.  Such  notice  of  impending
formulary and deductible, copayment or coinsurance changes shall also be
posted  on  the  corporation's  online formulary and in any prescription
drug finder system that the corporation provides to the public.
(5) The provisions of this subsection shall not supersede the terms of
a collective bargaining agreement, or the rights of labor representation
groups to collectively bargain changes to the formularies.
* NB There are 2 sb (c)'s
* (c) 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
immediately  obtain,  on  the insured's behalf, an additional thirty-day
supply of any current prescription of the insured, except as provided in
section two hundred seventy-eight-a of the public  health  law,  at  the
same level of coverage as a normal refill of such prescription drug upon
the  declaration  of  a  state  disaster  emergency  pursuant to section
twenty-eight of the executive law.
* NB There are 2 sb (c)'s