New York A 5282: Relates to access to appropriate drugs at reasonable prices, formulary exceptions, standing prior authorizations and external appeals

Bill Text

STATE OF NEW YORK
        ________________________________________________________________________
                                          5282
                               2025-2026 Regular Sessions
                   IN ASSEMBLY
                                    February 12, 2025
                                       ___________
        Introduced  by M. of A. SOLAGES, TAYLOR, SEAWRIGHT, RAMOS, SIMON, ROSEN-
          THAL, GLICK, BENDETT -- read once and referred  to  the  Committee  on
          Insurance
        AN ACT to amend the insurance law and the public health law, in relation
          to  access  to  appropriate  drugs  at  reasonable  prices,  formulary
          exceptions, standing prior authorizations  and  external  appeals;  to
          amend  the  insurance law, in relation to access to retail pharmacies,
          prescription synchronization, limits on patient drug  costs,  explana-
          tions  of  benefits  and rebates; to amend the social services law, in
          relation to prescription drug synchronization; and to amend the educa-
          tion law, in relation to limits on copayments and drug substitutions
          The People of the State of New York, represented in Senate and  Assem-
        bly, do enact as follows:
     1    Section  1.  The insurance law is amended by adding a new section 4807
     2  to read as follows:
     3    § 4807. Access to appropriate drugs at  reasonable  prices;  formulary
     4  exceptions;  standing  prior  authorization  requirement. (a) An insurer
     5  offering a prescription drug benefit with a  formulary  of  approved  or
     6  preferred  drugs  shall  establish  a  procedure  by which it determines
     7  whether a formulary drug provides appropriate  therapeutic  benefits  to
     8  meet  the  particular  health  care  needs of an insured. If the insurer
     9  determines that no formulary drug provides appropriate therapeutic bene-
    10  fits to meet the particular health care needs of an insured, the insurer
    11  shall cover the cost of an off-formulary drug for that  insured,  at  no
    12  additional  cost  to the insured beyond what the insured would otherwise
    13  pay for a preferred brand name drug on the formulary. The determinations
    14  whether a drug provides appropriate therapeutic benefits and  whether  a
    15  non-formulary drug is necessary to meet the particular health care needs
    16  of  the  insured  are utilization review decisions and are reviewable in
    17  accordance with article forty-nine of this chapter,  including  external
    18  appeal.
         EXPLANATION--Matter in  (underscored) is new; matter in bracketsitalics
                              [] is old law to be omitted. 
                                                                   LBD09173-01-5

        A. 5282                             2
     1    (b)  (1)  For  purposes of this section, "prior authorization require-
     2  ment" means any practice implemented by an insurer in which coverage  of
     3  a  prescription  drug  or device is dependent upon a covered person or a
     4  health care practitioner obtaining approval from the  insurer  prior  to
     5  the  service,  device, or drug being performed, received, or prescribed,
     6  as applicable. "Prior authorization" includes prospective or utilization
     7  review procedures conducted prior to providing a drug or device.
     8    (2) An insurer which  requires  prior  authorizations  for  particular
     9  prescription  drugs  shall  have  a procedure by which an insured who is
    10  being prescribed such drug for a chronic condition may obtain a standing
    11  prior authorization for a drug for the lesser of the following from  the
    12  date  of  the  approval:  (i) twelve months; or (ii) the last day of the
    13  covered person's eligibility under the policy or plan.
    14    (3) As a condition of such standing prior authorization, if  according
    15  to  the  available medical and scientific evidence the patient's chronic
    16  condition is likely to change during the standing referral  period,  the
    17  insurer  or  health plan may require the prescribing health care practi-
    18  tioner to certify to the insurer, not more frequently than on a quarter-
    19  ly basis, that the patient's chronic condition  has  not  changed  mate-
    20  rially with respect to the need for the prescription.
    21    (4)  A  twelve-month standing prior authorization provided under para-
    22  graph two of this subsection does not apply to and is not  required  for
    23  any of the following:
    24    (i)  medications  that have a typical course of administration of less
    25  than one year or for which available medical or scientific evidence does
    26  not support a twelve-month period of use, in  which  case  the  standing
    27  prior authorization period shall be the typical course of administration
    28  or  the