New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter A - Life, Accident and Health Insurance › Part 52 - Minimum Standards For Form, Content And Sale Of Health Insurance, Including Standards Of Full And Fair Disclosure › Section 52.74 - Coverage of contraceptive drugs, devices, or products

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Pursuant to Insurance Law sections
				  3216(i)(17)(E),
				  322 1(l)(16), and 4303(cc), every policy
				  that provides medical, major medical, or similar comprehensive type coverage
				  shall provide coverage for all FDA- approved contraceptive drugs, devices, and
				  other products . Where the FDA has approved one or more therapeutic and
				  pharmaceutical equivalent, as defined by the FDA, versions of a contraceptive
				  drug, device, or product, an insurer shall not be required to include all such
				  therapeutic and pharmaceutical equivalent versions in its formulary, as long as
				  at least one is included and covered without cost-sharing. If the covered
				  contraceptive drug, device, or product is not available or is deemed medically
				  inadvisable, an insurer shall provide coverage for an alternate therapeutic and
				  pharmaceutical equivalent version of the contraceptive drug, device, or product
				  without cost-sharing.
(b)
(1) Pursuant to Insurance Law sections
				  3216(i)(17)(E),
				  3221(l)(16), and
				  4303(cc), an insured, an
				  insured's design ee, or an insured's health care provider may submit a request
				  to an insurer for coverage of a non-covered contraceptive drug, device, or
				  product. Such request shall indicate whether the covered contraceptive d rug,
				  device, or product is not available or is medically inadvisable for the
				  insured. An insurer may require that the request for coverage be in writing.
				  The insurer shall use the exception form promulgated by the superintendent if
				  the insurer requires a written request.
(2) If the attending health care provider, in
				  his or her reasonable professional judgment, determines that the use of a
				  specific non-covered therapeutic or pharmaceutical equivalent of a drug,
				  device, or product is warranted, the health care provider's determination shall
				  be final.
(3)
(i) The insurer shall provide coverage of the
				  non-covered contraceptive drug, device, or product within 72 hours of receipt
				  of a standard request not based on exigent circumstances. The insurer shall
				  provide coverage of the non-covered contraceptive drug, device, or product
				  within 24 hours of receipt of an expedited request based on exigent
				  circumstances. In both situations, the insurer shall provide such coverage
				  without cost- sharing.
(ii) For
				  purposes of this paragraph, "exigent circumstances" means a circumstance under
				  which an insured is suffering from a health condition that may seriously
				  jeopardize the insured's life, health, or ability to regain maximum function or
				  is undergoing a current course of treatment using a non-covered contraceptive
				  drug, device, or product.