Assembly Bill A8278

                            
                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                 8278--A

                       2009-2010 Regular Sessions

                          I N  A S S E M B L Y

                              May 12, 2009
                               ___________

Introduced  by  M.  of  A.  KELLNER,  GOTTFRIED,  REILLY,  KOON, JACOBS,
  CYMBROWITZ, COOK, LANCMAN,  ROSENTHAL,  BOYLAND,  ESPAILLAT,  GUNTHER,
  BENEDETTO,  JAFFEE,  MENG,  CAHILL,  V. LOPEZ, GALEF, HOOPER -- Multi-
  Sponsored by -- M. of A.  BURLING, GLICK, McDONOUGH,  McENENY,  PERRY,
  SCHIMEL, SWEENEY, THIELE, TITONE, WEISENBERG -- read once and referred
  to  the  Committee  on  Insurance  --  recommitted to the Committee on
  Insurance in accordance with Assembly Rule  3,  sec.  2  --  committee
  discharged, bill amended, ordered reprinted as amended and recommitted
  to said committee

AN ACT to amend the public health law and the insurance law, in relation
  to  cost-sharing,  deductible or co-insurance for tier IV prescription
  drugs; and to amend the executive law, in relation to unlawful discri-
  minatory practice in relation to tier IV prescription drugs

  THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section  1.  Legislative  findings.  The cost-sharing, deductibles and
co-insurance obligations for certain drugs have become cost  prohibitive
for persons trying to overcome serious diseases such as cancer, multiple
sclerosis,  rheumatoid  arthritis,  hepatitis  C,  and hemophilia. These
drugs are typically new, produced in lesser quantities than other drugs,
and not available as less expensive brand name or  generic  prescription
drugs.  Some health insurance plans and policies have established unique
categories or specialty tiers for these drugs, sometimes referred to  as
Tier  IV  or  Tier  V.  Patients under these plans are required to pay a
percentage of the cost of  these  high-priced  drugs,  rather  than  the
traditional  co-payment  amounts  for generic, preferred brand, and non-
preferred brand prescription drugs, often covered by Tier  I,  Tier  II,
and  Tier  III  plans  and policies, respectively. As a result, patients
covered under Tier IV or Tier V plans or policies must pay thousands  of
dollars in out-of-pocket costs for drugs critical for their treatment.

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD11409-03-0

              

A. 8278--A                          2

  It  is  in  the  public  interest to help patients to afford necessary
prescription drugs by prohibiting cost-sharing, deductibles and co-insu-
rance obligations by patients that  exceed  payments  for  non-preferred
brand prescription drugs or the equivalent thereof. It is not the intent
of  this  legislation  to  preclude  plans or policies from categorizing
drugs used in the treatment of  these  common  diseases  as  brand  name
prescription drugs or generic prescription drug equivalents.
  The  extraordinary  disparity in cost-sharing, deductible and co-insu-
rance burdens imposed on patients whose life and health depend on  these
drugs  constitutes serious and unjustified discrimination based on their
disease or disability.
  This legislation is  intended  to  provide  patients  more  affordable
access  to  prescription  drugs essential for their treatment of cancer,
multiple sclerosis, rheumatoid arthritis, hepatitis  C,  hemophilia  and
other diseases.
  S  2.  Section  4406-c of the public health law is amended by adding a
new subdivision 7 to read as follows:
  7. NO HEALTH CARE PLAN WHICH PROVIDES COVERAGE FOR PRESCRIPTION  DRUGS
AND  FOR WHICH COST-SHARING, DEDUCTIBLES OR CO-INSURANCE OBLIGATIONS ARE
DETERMINED BY CATEGORY OF PRESCRIPTION DRUGS INCLUDING, BUT NOT  LIMITED
TO,  GENERIC DRUGS, PREFERRED BRAND DRUGS AND NON-PREFERRED BRAND DRUGS,
SHALL IMPOSE COST-SHARING, DEDUCTIBLES OR CO-INSURANCE  OBLIGATIONS  FOR
ANY  PRESCRIPTION  DRUG  THAT EXCEEDS THE DOLLAR AMOUNT OF COST-SHARING,
DEDUCTIBLES OR CO-INSURANCE OBLIGATIONS FOR ANY OTHER PRESCRIPTION  DRUG
PROVIDED  UNDER  SUCH  COVERAGE  IN  THE CATEGORY OF NON-PREFERRED BRAND
DRUGS OR ITS EQUIVALENT.
  S 3. Subsection (i) of section 3216 of the insurance law is amended by
adding a new paragraph 27 to read as follows:
  (27) NO POLICY DELIVERED OR ISSUED FOR DELIVERY IN  THIS  STATE  WHICH
PROVIDES  COVERAGE  FOR  PRESCRIPTION  DRUGS AND FOR WHICH COST-SHARING,
DEDUCTIBLES OR CO-INSURANCE OBLIGATIONS ARE DETERMINED  BY  CATEGORY  OF
PRESCRIPTION  DRUGS  INCLUDING,  BUT  NOT  LIMITED  TO,  GENERIC  DRUGS,
PREFERRED BRAND DRUGS AND NON-PREFERRED BRAND DRUGS, SHALL IMPOSE  COST-
SHARING,  DEDUCTIBLES  OR  CO-INSURANCE OBLIGATIONS FOR ANY PRESCRIPTION
DRUG THAT EXCEEDS THE DOLLAR  AMOUNT  OF  COST-SHARING,  DEDUCTIBLES  OR
CO-INSURANCE  OBLIGATIONS FOR ANY OTHER PRESCRIPTION DRUG PROVIDED UNDER
SUCH COVERAGE IN THE CATEGORY OF NON-PREFERRED BRAND DRUGS OR ITS EQUIV-
ALENT.
  S 4. Subsection (a) of section 3221 of the insurance law is amended by
adding a new paragraph 16 to read as follows:
  (16) NO POLICY DELIVERED OR ISSUED FOR DELIVERY IN  THIS  STATE  WHICH
PROVIDES  COVERAGE  FOR  PRESCRIPTION  DRUGS AND FOR WHICH COST-SHARING,
DEDUCTIBLES OR CO-INSURANCE OBLIGATIONS ARE DETERMINED  BY  CATEGORY  OF
PRESCRIPTION  DRUGS  INCLUDING,  BUT  NOT  LIMITED  TO,  GENERIC  DRUGS,
PREFERRED BRAND DRUGS AND NON-PREFERRED BRAND DRUGS, SHALL IMPOSE  COST-
SHARING,  DEDUCTIBLES  OR  CO-INSURANCE OBLIGATIONS FOR ANY PRESCRIPTION
DRUG THAT EXCEEDS THE DOLLAR  AMOUNT  OF  COST-SHARING,  DEDUCTIBLES  OR
CO-INSURANCE  OBLIGATIONS FOR ANY OTHER PRESCRIPTION DRUG PROVIDED UNDER
SUCH COVERAGE IN THE CATEGORY OF NON-PREFERRED BRAND DRUGS OR ITS EQUIV-
ALENT.
  S 5. Section 4303 of the insurance law is  amended  by  adding  a  new
subsection (gg) to read as follows:
  (GG)  NO  MEDICAL  EXPENSE  INDEMNITY  CORPORATION, A HOSPITAL SERVICE
CORPORATION OR A HEALTH SERVICE CORPORATION WHICH PROVIDES COVERAGE  FOR
PRESCRIPTION  DRUGS  AND FOR WHICH COST-SHARING, DEDUCTIBLES OR CO-INSU-
RANCE OBLIGATIONS ARE  DETERMINED  BY  CATEGORY  OF  PRESCRIPTION  DRUGS

A. 8278--A                          3

INCLUDING,  BUT NOT LIMITED TO, GENERIC DRUGS, PREFERRED BRAND DRUGS AND
NON-PREFERRED BRAND DRUGS, SHALL  IMPOSE  COST-SHARING,  DEDUCTIBLES  OR
CO-INSURANCE  OBLIGATIONS  FOR  ANY  PRESCRIPTION  DRUG THAT EXCEEDS THE
DOLLAR  AMOUNT  OF COST-SHARING, DEDUCTIBLES OR CO-INSURANCE OBLIGATIONS
FOR ANY OTHER PRESCRIPTION DRUG PROVIDED  UNDER  SUCH  COVERAGE  IN  THE
CATEGORY OF NON-PREFERRED BRAND DRUGS OR ITS EQUIVALENT.
  S  6.  Section  4321  of  the insurance law is amended by adding a new
subsection (g) to read as follows:
  (G) NO POLICY DELIVERED OR ISSUED FOR DELIVERY  IN  THIS  STATE  WHICH
PROVIDES  COVERAGE  FOR  PRESCRIPTION  DRUGS AND FOR WHICH COST-SHARING,
DEDUCTIBLES OR CO-INSURANCE OBLIGATIONS ARE DETERMINED  BY  CATEGORY  OF
PRESCRIPTION  DRUGS  INCLUDING,  BUT  NOT  LIMITED  TO,  GENERIC  DRUGS,
PREFERRED BRAND DRUGS AND NON-PREFERRED BRAND DRUGS, SHALL IMPOSE  COST-
SHARING,  DEDUCTIBLES  OR  CO-INSURANCE OBLIGATIONS FOR ANY PRESCRIPTION
DRUG THAT EXCEEDS THE DOLLAR  AMOUNT  OF  COST-SHARING,  DEDUCTIBLES  OR
CO-INSURANCE  OBLIGATIONS FOR ANY OTHER PRESCRIPTION DRUG PROVIDED UNDER
SUCH COVERAGE IN THE CATEGORY OF NON-PREFERRED BRAND DRUGS OR ITS EQUIV-
ALENT.
  S 7. Subdivision 20 of section 296 of the executive law, as renumbered
by chapter 204 of the laws of 1996, is renumbered subdivision 21  and  a
new subdivision 20 is added to read as follows:
  20.  IT SHALL BE AN UNLAWFUL DISCRIMINATORY PRACTICE FOR ANY EMPLOYER,
LABOR ORGANIZATION, INSURER, HEALTH MAINTENANCE  ORGANIZATION  OR  OTHER
ENTITY TO LIMIT HEALTH CARE COVERAGE SUCH THAT COST-SHARING, DEDUCTIBLES
OR CO-INSURANCE OBLIGATIONS FOR ANY PRESCRIPTION DRUG EXCEEDS THE DOLLAR
AMOUNT  OF COST-SHARING, DEDUCTIBLES OR CO-INSURANCE OBLIGATIONS FOR ANY
OTHER PRESCRIPTION DRUG PROVIDED UNDER SUCH HEALTH CARE COVERAGE IN  THE
CATEGORY OF NON-PREFERRED BRAND DRUGS OR ITS EQUIVALENT.
  S 8. Severability. If any provision of this act, or any application of
any provision of this act, is held to be invalid, or ruled by any feder-
al  agency to violate or be inconsistent with any applicable federal law
or regulation, that shall not affect the validity  or  effectiveness  of
any  other  provision  of  this  act, or of any other application of any
provision of this act.
  S 9. This act shall take effect on the thirtieth day  after  it  shall
have become a law.

                            
                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                 8278--B

                       2009-2010 Regular Sessions

                          I N  A S S E M B L Y

                              May 12, 2009
                               ___________

Introduced  by  M.  of  A.  KELLNER,  GOTTFRIED,  REILLY,  KOON, JACOBS,
  CYMBROWITZ, COOK, LANCMAN,  ROSENTHAL,  BOYLAND,  ESPAILLAT,  GUNTHER,
  BENEDETTO,  JAFFEE,  MENG,  CAHILL,  V. LOPEZ,  GALEF, HOOPER, POWELL,
  SPANO, CASTRO, MAISEL, PEOPLES-STOKES,  P. RIVERA,  HEVESI  --  Multi-
  Sponsored  by  --  M. of A.  BRODSKY, BURLING, GLICK, LATIMER, LIFTON,
  LUPARDO, McDONOUGH, McENENY, J. MILLER, PAULIN, PERRY, PHEFFER,  PRET-
  LOW,  SCHIMEL, SWEENEY, THIELE, TITONE, TOWNS, WEISENBERG -- read once
  and referred to the Committee  on  Insurance  --  recommitted  to  the
  Committee  on  Insurance in accordance with Assembly Rule 3, sec. 2 --
  committee discharged, bill amended, ordered reprinted as  amended  and
  recommitted  to  said  committee -- again reported from said committee
  with amendments, ordered reprinted as amended and recommitted to  said
  committee

AN ACT to amend the public health law and the insurance law, in relation
  to  cost-sharing,  deductible or co-insurance for tier IV prescription
  drugs; and to amend the executive law, in relation to unlawful discri-
  minatory practice in relation to tier IV prescription drugs

  THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section  1.  Legislative  findings.  The cost-sharing, deductibles and
co-insurance obligations for certain drugs are becoming cost prohibitive
for persons  trying  to  overcome  serious  and  often  life-threatening
diseases  and  conditions such as cancer, multiple sclerosis, rheumatoid
arthritis, hepatitis C, hemophilia and psoriasis.  These drugs are typi-
cally new, produced in lesser  quantities  than  other  drugs,  and  not
available  as  less  expensive brand name or generic prescription drugs.
Some health insurance plans and policies in other states as well as some
self-insured plans in New York have  established  unique  categories  or
specialty  tiers  for  these  drugs, sometimes referred to as Tier IV or
Tier V. Patients under these plans are required to pay a  percentage  of
the cost of these high-priced drugs, rather than the traditional co-pay-

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD11409-04-0
              

A. 8278--B                          2

ment  amounts  for  generic,  preferred  brand,  and non-preferred brand
prescription drugs, often covered by Tier I, Tier II, and Tier III plans
and policies, respectively. As a result, patients  covered  under  plans
with  specialty  tiers  must  pay  thousands of dollars in out-of-pocket
costs for drugs critical for their treatment.
  It is in the public interest to  help  patients  to  afford  necessary
prescription drugs by prohibiting cost-sharing, deductibles and co-insu-
rance  obligations  by  patients  that exceed payments for non-preferred
brand prescription drugs or the equivalent thereof. It is not the intent
of this legislation to preclude  plans  or  policies  from  categorizing
drugs  used  in  the  treatment  of  these common diseases as brand name
prescription drugs or generic prescription drug equivalents.
  The extraordinary disparity in cost-sharing, deductible  and  co-insu-
rance  burdens imposed on patients whose life and health depend on these
drugs constitutes serious and unjustified discrimination based on  their
disease or disability.
  This  legislation  is  intended  to  provide  patients more affordable
access to prescription drugs essential for their  treatment  of  cancer,
multiple  sclerosis,  rheumatoid  arthritis,  hepatitis  C,  hemophilia,
psoriasis, and other diseases.
  S 2. Section 4406-c of the public health law is amended  by  adding  a
new subdivision 7 to read as follows:
  7.  NO  HEALTH  MAINTENANCE  ORGANIZATION  WHICH PROVIDES COVERAGE FOR
PRESCRIPTION DRUGS AND FOR WHICH COST-SHARING, DEDUCTIBLES  OR  CO-INSU-
RANCE OBLIGATIONS ARE DETERMINED BY CATEGORY OF PRESCRIPTION DRUGS SHALL
IMPOSE  COST-SHARING,  DEDUCTIBLES  OR  CO-INSURANCE OBLIGATIONS FOR ANY
PRESCRIPTION DRUG THAT EXCEEDS THE DOLLAR AMOUNT OF COST-SHARING, DEDUC-
TIBLES OR CO-INSURANCE OBLIGATIONS FOR NON-PREFERRED BRAND DRUGS OR  ITS
EQUIVALENT (OR BRAND DRUGS IF THERE IS NO NON-PREFERRED BRAND DRUG CATE-
GORY).
  S 3. Subsection (i) of section 3216 of the insurance law is amended by
adding a new paragraph 27 to read as follows:
  (27)  NO  POLICY  DELIVERED OR ISSUED FOR DELIVERY IN THIS STATE WHICH
PROVIDES COVERAGE FOR PRESCRIPTION DRUGS  AND  FOR  WHICH  COST-SHARING,
DEDUCTIBLES  OR  CO-INSURANCE  OBLIGATIONS ARE DETERMINED BY CATEGORY OF
PRESCRIPTION DRUGS SHALL IMPOSE COST-SHARING,  DEDUCTIBLES  OR  CO-INSU-
RANCE  OBLIGATIONS  FOR  ANY  PRESCRIPTION  DRUG THAT EXCEEDS THE DOLLAR
AMOUNT OF COST-SHARING,  DEDUCTIBLES  OR  CO-INSURANCE  OBLIGATIONS  FOR
NON-PREFERRED  BRAND DRUGS OR ITS EQUIVALENT (OR BRAND DRUGS IF THERE IS
NO NON-PREFERRED BRAND DRUG CATEGORY).
  S 4. Subsection (a) of section 3221 of the insurance law is amended by
adding a new paragraph 16 to read as follows:
  (16) NO POLICY DELIVERED OR ISSUED FOR DELIVERY IN  THIS  STATE  WHICH
PROVIDES  COVERAGE  FOR  PRESCRIPTION  DRUGS AND FOR WHICH COST-SHARING,
DEDUCTIBLES OR CO-INSURANCE OBLIGATIONS ARE DETERMINED  BY  CATEGORY  OF
PRESCRIPTION  DRUGS  SHALL  IMPOSE COST-SHARING, DEDUCTIBLES OR CO-INSU-
RANCE OBLIGATIONS FOR ANY PRESCRIPTION  DRUG  THAT  EXCEEDS  THE  DOLLAR
AMOUNT  OF  COST-SHARING,  DEDUCTIBLES  OR  CO-INSURANCE OBLIGATIONS FOR
NON-PREFERRED BRAND DRUGS OR ITS EQUIVALENT (OR BRAND DRUGS IF THERE  IS
NO NON-PREFERRED BRAND DRUG CATEGORY).
  S  5.  Section  4303  of  the insurance law is amended by adding a new
subsection (gg) to read as follows:
  (GG) NO MEDICAL EXPENSE  INDEMNITY  CORPORATION,  A  HOSPITAL  SERVICE
CORPORATION  OR A HEALTH SERVICE CORPORATION WHICH PROVIDES COVERAGE FOR
PRESCRIPTION DRUGS AND FOR WHICH COST-SHARING, DEDUCTIBLES  OR  CO-INSU-
RANCE OBLIGATIONS ARE DETERMINED BY CATEGORY OF PRESCRIPTION DRUGS SHALL

A. 8278--B                          3

IMPOSE  COST-SHARING,  DEDUCTIBLES  OR  CO-INSURANCE OBLIGATIONS FOR ANY
PRESCRIPTION DRUG THAT EXCEEDS THE DOLLAR AMOUNT OF COST-SHARING, DEDUC-
TIBLES OR CO-INSURANCE OBLIGATIONS FOR NON-PREFERRED BRAND DRUGS OR  ITS
EQUIVALENT (OR BRAND DRUGS IF THERE IS NO NON-PREFERRED BRAND DRUG CATE-
GORY).
  S  6.    Subdivision 20 of section 296 of the executive law, as renum-
bered by chapter 204 of the laws of 1996, is renumbered  subdivision  21
and a new subdivision 20 is added to read as follows:
  20.  IT SHALL BE AN UNLAWFUL DISCRIMINATORY PRACTICE FOR ANY EMPLOYER,
LABOR ORGANIZATION, INSURER, HEALTH MAINTENANCE  ORGANIZATION  OR  OTHER
ENTITY TO LIMIT HEALTH CARE COVERAGE SUCH THAT COST-SHARING, DEDUCTIBLES
OR CO-INSURANCE OBLIGATIONS FOR ANY PRESCRIPTION DRUG EXCEEDS THE DOLLAR
AMOUNT  OF COST-SHARING, DEDUCTIBLES OR CO-INSURANCE OBLIGATIONS FOR ANY
OTHER PRESCRIPTION DRUG PROVIDED UNDER SUCH HEALTH CARE COVERAGE IN  THE
CATEGORY  OF NON-PREFERRED BRAND DRUGS OR ITS EQUIVALENT (OR BRAND DRUGS
IF THERE IS NO NON-PREFERRED BRAND  DRUG  CATEGORY);  PROVIDED  HOWEVER,
THIS  SUBDIVISION  SHALL  NOT APPLY TO ANY SELF-INSURED EMPLOYEE WELFARE
BENEFIT PLAN, AS DEFINED IN THE EMPLOYEE RETIREMENT INCOME SECURITY  ACT
OF 1974, AS AMENDED.
  S 7. Severability. If any provision of this act, or any application of
any provision of this act, is held to be invalid, or ruled by any feder-
al  agency to violate or be inconsistent with any applicable federal law
or regulation, that shall not affect the validity  or  effectiveness  of
any  other  provision  of  this  act, or of any other application of any
provision of this act.
  S 8. This act shall take effect on the thirtieth day  after  it  shall
have become a law.