Assembly Bill A3973A

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   3973
 
                        2025-2026 Regular Sessions
 
                           I N  A S S E M B L Y
 
                             January 30, 2025
                                ___________
 
 Introduced by M. of A. McDONALD -- read once and referred to the Commit-
   tee on Insurance
 
 AN  ACT  to  amend  the  insurance law, in relation to prescription drug
   formulary coverage for interchangeable biologics and biosimilars
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section  1.  Paragraph  4  of  subsection (c-1) of section 4903 of the
 insurance law, as added by chapter 512 of the laws of 2016,  is  amended
 to read as follows:
   (4)  The insured is stable on a prescription drug or drugs selected by
 their health care professional for the medical condition under consider-
 ation, provided that this shall not prevent a utilization  review  agent
 from  [requiring  an insured to try an AB-rated generic equivalent prior
 to providing coverage for the equivalent brand name prescription drug or
 drugs; or]:
   (I) REQUIRING AN INSURED TO TRY AN AB-RATED GENERIC EQUIVALENT  OR  AN
 INTERCHANGEABLE  BIOLOGICAL  PRODUCT PRIOR TO PROVIDING COVERAGE FOR THE
 EQUIVALENT BRAND NAME PRESCRIPTION DRUG OR DRUGS, OR
   (II) REQUIRING AN INSURED TO  TRY  A  BIOSIMILAR  PRIOR  TO  PROVIDING
 COVERAGE  FOR  THE  BRAND  NAME  PRESCRIPTION  REFERENCE PRODUCT DRUG OR
 DRUGS.
   § 2. Subparagraph (A) of paragraph 3 of subsection (c) of section 3242
 of the insurance law, as added by chapter 99 of the  laws  of  2022,  is
 amended to read as follows:
   (A)  An  insurer  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], AN interchangeable biological product,
 OR  BIOSIMILAR for such prescription drug is added to  the  formulary at
 the same time; PROVIDED THE CHANGE IS NOT APPLICABLE TO AN  INSURED  WHO
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD03429-02-5
              

 A. 3973                             2
 
 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 PLAN FOR SUCH CONDITION.
   §  3.    Subparagraph  (A) of paragraph 3 of subsection (c) of section
 4329 of the insurance law, as added by chapter 99 of the laws  of  2022,
 is amended to read as follows:
   (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], AN interchangeable biological product,
 OR  BIOSIMILAR  for  such prescription drug is added to the formulary at
 the same time; 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 CONDI-
 TION.
   § 4. Subsection (c) of section 3242 of  the  insurance  law, as  added
 by chapter 99 of the laws of 2022, is redesignated subsection (d).
   §  5. Subsection (c) of section 4329 of the insurance law, as added by
 chapter 99 of the laws  of  2022, is redesignated subsection (d).
   § 6. This act shall take effect immediately.