LBD00167-01-9
A. 2810 2
ORDER RETAIL PHARMACIES, AND PROVIDED FURTHER THAT ANY SUCH STANDARD
TERMS AND CONDITIONS THAT REQUIRE:
(I) CONSULTATION WITH A PHARMACIST SHALL NOT REQUIRE SUCH CONSULTATION
BE AVAILABLE AT NON-MAIL ORDER PHARMACIES OUTSIDE OF SUCH PHARMACY'S
REGULAR HOURS OF OPERATION AND SHALL REQUIRE MAIL ORDER PHARMACIES TO
PROVIDE SUCH CONSULTATION TWENTY-FOUR HOURS A DAY, SEVEN DAYS A WEEK;
(II) SPECIFIC STORAGE SIZE FOR PRESCRIPTION DRUGS REQUIRING SPECIAL
HANDLING, SUCH AS REFRIGERATION, SHALL BE BASED ON THE CONTRACTING PHAR-
MACY'S DISPENSING EXPERIENCE AND SHALL NOT REQUIRE A PHARMACY TO
INCREASE ITS STORAGE SPACE WHEN IT HAS NOT BEEN ESTABLISHED THAT SUCH
PHARMACY'S PRESCRIPTION VOLUME REQUIRES SUCH INCREASED STORAGE; AND
(III) SPECIFIC STORAGE SPACE FOR PRESCRIPTION DRUGS THAT DO NOT
REQUIRE SPECIAL HANDLING SHALL BE BASED ON THE CONTRACTING PHARMACY'S
PHYSICAL SIZE AND DISPENSING EXPERIENCE AND SHALL NOT REQUIRE A PHARMACY
TO INCREASE ITS STORAGE SPACE WHEN IT HAS NOT BEEN ESTABLISHED THAT SUCH
PHARMACY'S PRESCRIPTION VOLUME REQUIRES SUCH INCREASED STORAGE.
(B) Every policy that provides coverage for prescription fertility
drugs and requires or permits prescription drugs to be purchased through
a network participating mail order or other non-retail pharmacy shall
provide the same coverage for prescription fertility drugs AND SHALL NOT
LIMIT THE SUPPLY THAT MAY BE DISPENSED TO A THIRTY-DAY SUPPLY when such
drugs are purchased from a network participating non-mail order retail
pharmacy provided that the network participating non-mail order retail
pharmacy agrees [in advance through a contractual network agreement,] to
the same reimbursement amount[, as well as the same applicable terms and
conditions,] AND STANDARD TERMS AND CONDITIONS that the insurer has
established for [a] network participating [mail order or other non-re-
tail pharmacy] PHARMACIES. In such case, the policy shall not impose
any fee, co-payment, co-insurance, deductible or other condition,
INCLUDING REQUIRING MONTHLY REFILLS OF A PRESCRIPTION THAT WAS WRITTEN
FOR AND MAY BE FILLED FOR MORE THAN A THIRTY-DAY SUPPLY, on any insured
who elects to purchase prescription fertility drugs through a network
participating non-mail order retail pharmacy that it does not impose on
any insured who purchases prescription fertility drugs through a network
participating mail order or other non-retail pharmacy.
(C) ANY POLICY THAT PROVIDES COVERAGE FOR PRESCRIPTION FERTILITY DRUGS
SHALL, IN ADDITION TO THE STANDARD TERMS AND CONDITIONS, REQUIRE MAIL
ORDER PHARMACIES TO REPLACE DISPENSED PRESCRIPTION FERTILITY DRUGS FOR
WHICH THE MAIL OR CARRIER SERVICE HAS PROOF OF DELIVERY THAT HAVE NOT
BEEN RECEIVED BY THE INSURED, OR ARE SPOILED OR DAMAGED, PROVIDED THAT
IN THE CASE OF A PRESCRIPTION FERTILITY DRUG THAT HAS NOT BEEN RECEIVED
BY THE INSURED, THE POLICY MAY REQUIRE THAT THE INSURED PROVIDE PROOF OF
THEFT IN THE FORM OF A FILED POLICE REPORT REPORTING THE THEFT AND IN
THE CASE OF A DAMAGED OR SPOILED PRESCRIPTION FERTILITY DRUG, THE POLICY
MAY REQUIRE THAT THE DAMAGED PRESCRIPTION FERTILITY DRUG BE RETURNED TO
THE MAIL ORDER PHARMACY WITH THE COST TO BE BORNE BY SUCH PHARMACY, AND
PROVIDED FURTHER THAT SUCH UNRECEIVED, SPOILED OR DAMAGED PRESCRIPTION
FERTILITY DRUG SHALL BE REPLACED BEFORE RECEIPT OF THE POLICE REPORT OR
THE RETURNED, SPOILED OR DAMAGED PRESCRIPTION FERTILITY DRUG, AS THE
CASE MAY BE. IF SUCH REQUIRED POLICE REPORT IS NOT PROVIDED OR THE
DAMAGED OR SPOILED PRESCRIPTION FERTILITY DRUG IS NOT RETURNED, THE
POLICY MAY REQUIRE THE INSURED TO REIMBURSE THE POLICY FOR THE COST OF
THE PRESCRIPTION FERTILITY DRUG AND, NOTWITHSTANDING THE FORGOING, WHEN
AN INSURED WHO WAS PREVIOUSLY REQUIRED TO REIMBURSE THE PLAN FOR A
DISPENSED PRESCRIPTION FERTILITY DRUG THAT WAS NOT RECEIVED BY THE
INSURED, OR WAS DAMAGED OR SPOILED, THE POLICY MAY REFUSE TO REPLACE
A. 2810 3
SUCH PRESCRIPTION FERTILITY DRUG FOR SUCH INSURED UNTIL SUCH INSURED HAS
PROVIDED THE PLAN WITH THE REQUIRED POLICE REPORT OR RETURNED THE
SPOILED OR DAMAGED PRESCRIPTION FERTILITY DRUG. REPLACEMENT OF A
PRESCRIPTION FERTILITY DRUG PURSUANT TO THIS SUBPARAGRAPH SHALL NOT BE
LIMITED TO A SPECIFIC NUMBER OF OCCURRENCES DURING A CONTRACT YEAR.
(28) (A) DEFINITIONS. FOR THE PURPOSES OF THIS PARAGRAPH:
(1) "SAME REIMBURSEMENT AMOUNT" SHALL MEAN THAT ANY COVERAGE DESCRIBED
UNDER SUBPARAGRAPH (B) OF THIS PARAGRAPH SHALL PROVIDE THE SAME BENCH-
MARK INDEX, INCLUDING THE SAME AVERAGE WHOLESALE PRICE, MAXIMUM ALLOW-
ABLE COST AND NATIONAL PRESCRIPTION DRUG CODES TO REIMBURSE ALL PHARMA-
CIES PARTICIPATING IN THE INSURANCE NETWORK REGARDLESS OF WHETHER A
PHARMACY IS A MAIL ORDER PHARMACY OR A NON-MAIL ORDER PHARMACY.
(2) "MAIL ORDER PHARMACY" SHALL MEAN A PHARMACY WHOSE PRIMARY BUSINESS
IS TO RECEIVE PRESCRIPTIONS BY MAIL, TELEFAX OR THROUGH ELECTRONIC
SUBMISSIONS AND TO DISPENSE MEDICATION TO PATIENTS THROUGH THE USE OF
THE UNITED STATES MAIL OR OTHER COMMON OR CONTRACT CARRIER SERVICES AND
PROVIDES ANY CONSULTATION WITH PATIENTS ELECTRONICALLY RATHER THAN FACE-
TO-FACE.
(3) "STANDARD TERMS AND CONDITIONS" SHALL MEAN THE CONTRACTUAL TERMS
AND CONDITIONS APPLICABLE TO ALL NETWORK PARTICIPATING PHARMACIES THAT
WERE IN EFFECT ON JUNE FIRST, TWO THOUSAND FIFTEEN; PROVIDED THAT IF AN
INSURER HAS ESTABLISHED DIFFERENT STANDARD TERMS AND CONDITIONS FOR MAIL
ORDER PHARMACIES AND NON-MAIL ORDER RETAIL PHARMACIES, THE TERM "STAND-
ARD TERMS AND CONDITIONS" SHALL MEAN THE STANDARD TERMS AND CONDITIONS
THAT WERE IN EFFECT ON JUNE FIRST, TWO THOUSAND FIFTEEN FOR NON-MAIL
ORDER RETAIL PHARMACIES, AND PROVIDED FURTHER THAT ANY SUCH STANDARD
TERMS AND CONDITIONS THAT REQUIRE:
(I) CONSULTATION WITH A PHARMACIST SHALL NOT REQUIRE SUCH CONSULTATION
BE AVAILABLE AT NON-MAIL ORDER PHARMACIES OUTSIDE OF SUCH PHARMACY'S
REGULAR HOURS OF OPERATION AND SHALL REQUIRE MAIL ORDER PHARMACIES TO
PROVIDE SUCH CONSULTATION TWENTY-FOUR HOURS A DAY, SEVEN DAYS A WEEK;
(II) SPECIFIC STORAGE SIZE FOR PRESCRIPTION DRUGS REQUIRING SPECIAL
HANDLING, SUCH AS REFRIGERATION, SHALL BE BASED ON THE CONTRACTING PHAR-
MACY'S DISPENSING EXPERIENCE AND SHALL NOT REQUIRE A PHARMACY TO
INCREASE ITS STORAGE SPACE WHEN IT HAS NOT BEEN ESTABLISHED THAT SUCH
PHARMACY'S PRESCRIPTION VOLUME REQUIRES SUCH INCREASED STORAGE; AND
(III) SPECIFIC STORAGE SPACE FOR PRESCRIPTION DRUGS THAT DO NOT
REQUIRE SPECIAL HANDLING SHALL BASE SUCH REQUIREMENTS ON THE CONTRACTING
PHARMACY'S PHYSICAL SIZE AND DISPENSING EXPERIENCE AND SHALL NOT REQUIRE
A PHARMACY TO INCREASE ITS STORAGE SPACE WHEN IT HAS NOT BEEN ESTAB-
LISHED THAT SUCH PHARMACY'S PRESCRIPTION VOLUME REQUIRES SUCH INCREASED
STORAGE.
(B) Any policy that provides coverage for prescription drugs shall
permit each insured to fill any covered prescription that may be
obtained at a network participating mail order or other non-retail phar-
macy, at the insured's option, at a network participating non-mail order
retail pharmacy provided that the network participating non-mail order
retail pharmacy agrees [in advance, through a contractual network agree-
ment,] to the same reimbursement amount[, as well as the same applicable
terms and conditions,] AND STANDARD TERMS AND CONDITIONS that the insur-
er has established for the network participating [mail order or other
non-retail pharmacy] PHARMACIES. In such a case, the policy shall not
impose a co-payment fee or other condition, INCLUDING REQUIRING MONTHLY
REFILLS OF A PRESCRIPTION THAT WAS WRITTEN FOR AND MAY BE FILLED FOR
MORE THAN A THIRTY-DAY SUPPLY, on any insured who elects to purchase
prescription drugs from a network participating non-mail order retail
A. 2810 4
pharmacy which is not also imposed on insureds electing to purchase
drugs from a network participating mail order or other non-retail phar-
macy.
(C) ANY POLICY THAT PROVIDES COVERAGE FOR PRESCRIPTION DRUGS SHALL, IN
ADDITION TO THE STANDARD TERMS AND CONDITIONS, REQUIRE MAIL ORDER PHAR-
MACIES TO REPLACE DISPENSED PRESCRIPTION DRUGS FOR WHICH THE MAIL OR
CARRIER SERVICE HAS PROOF OF DELIVERY THAT HAVE NOT BEEN RECEIVED BY THE
INSURED, OR ARE SPOILED OR DAMAGED, PROVIDED THAT IN THE CASE OF A
PRESCRIPTION DRUG THAT HAS NOT BEEN RECEIVED BY THE INSURED, THE POLICY
MAY REQUIRE THAT THE INSURED PROVIDE PROOF OF THEFT IN THE FORM OF A
FILED POLICE REPORT REPORTING THE THEFT AND IN THE CASE OF A DAMAGED OR
SPOILED PRESCRIPTION DRUG, THE POLICY MAY REQUIRE THAT THE DAMAGED
PRESCRIPTION DRUG BE RETURNED TO THE MAIL ORDER PHARMACY WITH THE COST
TO BE BORNE BY SUCH PHARMACY, AND PROVIDED FURTHER THAT SUCH UNRECEIVED,
SPOILED OR DAMAGED PRESCRIPTION DRUG SHALL BE REPLACED BEFORE RECEIPT OF
THE POLICE REPORT OR THE SPOILED OR DAMAGED PRESCRIPTION DRUG, AS THE
CASE MAY BE. IF SUCH REQUIRED POLICE REPORT IS NOT PROVIDED OR THE
DAMAGED OR SPOILED PRESCRIPTION DRUG IS NOT RETURNED, THE POLICY MAY
REQUIRE THE INSURED TO REIMBURSE THE POLICY FOR THE COST OF THE
PRESCRIPTION DRUG AND, NOTWITHSTANDING THE FORGOING, WHEN AN INSURED WHO
WAS PREVIOUSLY REQUIRED TO REIMBURSE THE PLAN FOR A DISPENSED
PRESCRIPTION DRUG THAT WAS NOT RECEIVED BY THE INSURED, OR WAS DAMAGED
OR SPOILED, THE POLICY MAY REFUSE TO REPLACE SUCH PRESCRIPTION DRUG FOR
SUCH INSURED UNTIL SUCH INSURED HAS PROVIDED THE PLAN WITH THE REQUIRED
POLICE REPORT OR RETUNED THE SPOILED OR DAMAGED PRESCRIPTION DRUG.
REPLACEMENT OF A PRESCRIPTION DRUG PURSUANT TO THIS SUBPARAGRAPH SHALL
NOT BE LIMITED TO A SPECIFIC NUMBER OF OCCURRENCES DURING A CONTRACT
YEAR.
§ 2. Subparagraph (D) of paragraph 6 of subsection (k) of section 3221
of the insurance law, as amended by chapter 10 of the laws of 2012, is
amended to read as follows:
(D) (I) DEFINITIONS. FOR THE PURPOSE OF THIS PARAGRAPH:
(1) "SAME REIMBURSEMENT AMOUNT" SHALL MEAN THAT ANY COVERAGE DESCRIBED
UNDER ITEM (II) OF THIS SUBPARAGRAPH SHALL PROVIDE THE SAME BENCHMARK
INDEX, INCLUDING THE SAME AVERAGE WHOLESALE PRICE, MAXIMUM ALLOWABLE
COST AND NATIONAL PRESCRIPTION DRUG CODES TO REIMBURSE ALL PHARMACIES
PARTICIPATING IN THE INSURANCE NETWORK REGARDLESS OF WHETHER A PHARMACY
IS A MAIL ORDER PHARMACY OR A NON-MAIL ORDER PHARMACY.
(2) "MAIL ORDER PHARMACY" SHALL MEAN A PHARMACY WHOSE PRIMARY BUSINESS
IS TO RECEIVE PRESCRIPTIONS BY MAIL, TELEFAX OR THROUGH ELECTRONIC
SUBMISSIONS AND TO DISPENSE MEDICATION TO PATIENTS THROUGH THE USE OF
THE UNITED STATES MAIL OR OTHER COMMON OR CONTRACT CARRIER SERVICES AND
PROVIDES ANY CONSULTATION WITH PATIENTS ELECTRONICALLY RATHER THAN FACE-
TO-FACE.
(3) "STANDARD TERMS AND CONDITIONS" SHALL MEAN THE CONTRACTUAL TERMS
AND CONDITIONS APPLICABLE TO ALL NETWORK PARTICIPATING PHARMACIES THAT
WERE IN EFFECT ON JUNE FIRST, TWO THOUSAND FIFTEEN; PROVIDED THAT IF AN
INSURER HAS ESTABLISHED DIFFERENT STANDARD TERMS AND CONDITIONS FOR MAIL
ORDER PHARMACIES AND NON-MAIL ORDER RETAIL PHARMACIES, THE TERM STANDARD
TERMS AND CONDITIONS SHALL MEAN THE STANDARD TERMS AND CONDITIONS THAT
WERE IN EFFECT ON JUNE FIRST, TWO THOUSAND FIFTEEN FOR NON-MAIL ORDER
RETAIL PHARMACIES, AND PROVIDED FURTHER THAT ANY SUCH STANDARD TERMS AND
CONDITIONS THAT REQUIRE:
A. CONSULTATION WITH A PHARMACIST SHALL NOT REQUIRE SUCH CONSULTATION
BE AVAILABLE AT NON-MAIL ORDER PHARMACIES OUTSIDE OF SUCH PHARMACY'S
A. 2810 5
REGULAR HOURS OF OPERATION AND SHALL REQUIRE MAIL ORDER PHARMACIES TO
PROVIDE SUCH CONSULTATION TWENTY-FOUR HOURS A DAY, SEVEN DAYS A WEEK;
B. SPECIFIC STORAGE SIZE FOR PRESCRIPTION DRUGS REQUIRING SPECIAL
HANDLING, SUCH AS REFRIGERATION, SHALL BE BASED ON THE CONTRACTING PHAR-
MACY'S DISPENSING EXPERIENCE AND SHALL NOT REQUIRE A PHARMACY TO
INCREASE ITS STORAGE SPACE WHEN IT HAS NOT BEEN ESTABLISHED THAT SUCH
PHARMACY'S PRESCRIPTION VOLUME REQUIRES SUCH INCREASED STORAGE; AND
C. SPECIFIC STORAGE SPACE FOR PRESCRIPTION DRUGS THAT DO NOT REQUIRE
SPECIAL HANDLING SHALL BE BASED ON THE CONTRACTING PHARMACY'S PHYSICAL
SIZE AND DISPENSING EXPERIENCE AND SHALL NOT REQUIRE A PHARMACY TO
INCREASE ITS STORAGE SPACE WHEN IT HAS NOT BEEN ESTABLISHED THAT SUCH
PHARMACY'S PRESCRIPTION VOLUME REQUIRES SUCH INCREASED STORAGE.
(II) Every policy that provides coverage for prescription fertility
drugs and requires or permits prescription drugs to be purchased through
a network participating mail order or other non-retail pharmacy shall
provide the same coverage for prescription fertility drugs AND SHALL NOT
LIMIT THE SUPPLY THAT MAY BE DISPENSED TO A THIRTY-DAY SUPPLY when such
drugs are purchased from a network participating non-mail order retail
pharmacy provided that the network participating non-mail order retail
pharmacy agrees [in advance through a contractual network agreement,] to
the same reimbursement amount[, as well as the same applicable terms and
conditions,] AND STANDARD TERMS AND CONDITIONS that the insurer has
established for [a] network participating [mail order or other non-re-
tail pharmacy] PHARMACIES. In such case, the policy shall not impose any
fee, co-payment, co-insurance, deductible or other condition, INCLUDING
REQUIRING MONTHLY REFILLS OF A PRESCRIPTION THAT WAS WRITTEN FOR AND MAY
BE FILLED FOR MORE THAN A THIRTY-DAY SUPPLY, on any covered person who
elects to purchase prescription fertility drugs through a network
participating non-mail order retail pharmacy that it does not impose on
any covered person who purchases prescription fertility drugs through a
network participating mail order or other non-retail pharmacy; provided,
however, that the provisions of this section shall not supersede the
terms of a collective bargaining agreement or apply to a policy that is
the result of a collective bargaining agreement between an employer and
a recognized or certified employee organization.
(III) ANY POLICY THAT PROVIDES COVERAGE FOR PRESCRIPTION FERTILITY
DRUGS SHALL, IN ADDITION TO THE STANDARD TERMS AND CONDITIONS, REQUIRE
MAIL ORDER PHARMACIES TO REPLACE DISPENSED PRESCRIPTION FERTILITY DRUGS
FOR WHICH THE MAIL OR CARRIER SERVICE HAS PROOF OF DELIVERY THAT HAVE
NOT BEEN RECEIVED BY THE INSURED, OR ARE SPOILED OR DAMAGED, PROVIDED
THAT IN THE CASE OF A PRESCRIPTION FERTILITY DRUG THAT HAS NOT BEEN
RECEIVED BY THE INSURED, THE POLICY MAY REQUIRE THAT THE INSURED PROVIDE
PROOF OF THEFT IN THE FORM OF A FILED POLICE REPORT REPORTING THE THEFT
AND IN THE CASE OF A DAMAGED OR SPOILED PRESCRIPTION FERTILITY DRUG, THE
POLICY MAY REQUIRE THAT THE DAMAGED PRESCRIPTION FERTILITY DRUG BE
RETURNED TO THE MAIL ORDER PHARMACY WITH THE COST TO BE BORNE BY SUCH
PHARMACY, AND PROVIDED FURTHER THAT SUCH UNRECEIVED, SPOILED OR DAMAGED
PRESCRIPTION FERTILITY DRUG SHALL BE REPLACED BEFORE RECEIPT OF THE
POLICE REPORT OR THE RETURNED SPOILED OR DAMAGED PRESCRIPTION FERTILITY
DRUG, AS THE CASE MAY BE. IF SUCH REQUIRED POLICE REPORT IS NOT PROVIDED
OR THE DAMAGED OR SPOILED PRESCRIPTION FERTILITY DRUG IS NOT RETURNED,
THE POLICY MAY REQUIRE THE INSURED TO REIMBURSE THE POLICY FOR THE COST
OF THE PRESCRIPTION FERTILITY DRUG AND, NOTWITHSTANDING THE FORGOING,
WHEN AN INSURED WHO WAS PREVIOUSLY REQUIRED TO REIMBURSE THE PLAN FOR A
DISPENSED PRESCRIPTION FERTILITY DRUG THAT WAS NOT RECEIVED BY THE
INSURED, OR WAS DAMAGED OR SPOILED, THE POLICY MAY REFUSE TO REPLACE
A. 2810 6
SUCH PRESCRIPTION FERTILITY DRUG FOR SUCH INSURED UNTIL SUCH INSURED HAS
PROVIDED THE PLAN WITH THE REQUIRED POLICE REPORT OR RETURNED THE
SPOILED OR DAMAGED PRESCRIPTION FERTILITY DRUG. REPLACEMENT OF A
PRESCRIPTION FERTILITY DRUG PURSUANT TO THIS CLAUSE SHALL NOT BE LIMITED
TO A SPECIFIC NUMBER OF OCCURRENCES DURING A CONTRACT YEAR.
§ 3. Paragraph 18 of subsection (l) of section 3221 of the insurance
law, as amended by chapter 11 of the laws of 2012, is amended to read as
follows:
(18) (A) DEFINITIONS. FOR THE PURPOSE OF THIS PARAGRAPH:
(1) "SAME REIMBURSEMENT AMOUNT" SHALL MEAN THAT ANY COVERAGE DESCRIBED
UNDER SUBPARAGRAPH (B) OF THIS PARAGRAPH SHALL PROVIDE THE SAME BENCH-
MARK INDEX, INCLUDING THE SAME AVERAGE WHOLESALE PRICE, MAXIMUM ALLOW-
ABLE COST AND NATIONAL PRESCRIPTION DRUG CODES TO REIMBURSE ALL PHARMA-
CIES PARTICIPATING IN THE INSURANCE NETWORK REGARDLESS OF WHETHER A
PHARMACY IS A MAIL ORDER PHARMACY OR A NON-MAIL ORDER PHARMACY.
(2) "MAIL ORDER PHARMACY" SHALL MEAN A PHARMACY WHOSE PRIMARY BUSINESS
IS TO RECEIVE PRESCRIPTIONS BY MAIL, TELEFAX OR THROUGH ELECTRONIC
SUBMISSIONS AND TO DISPENSE MEDICATION TO PATIENTS THROUGH THE USE OF
THE UNITED STATES MAIL OR OTHER COMMON OR CONTRACT CARRIER SERVICES AND
PROVIDES ANY CONSULTATION WITH PATIENTS ELECTRONICALLY RATHER THAN FACE-
TO-FACE.
(3) "STANDARD TERMS AND CONDITIONS" SHALL MEAN THE CONTRACTUAL TERMS
AND CONDITIONS APPLICABLE TO ALL NETWORK PARTICIPATING PHARMACIES THAT
WERE IN EFFECT ON JUNE FIRST, TWO THOUSAND FIFTEEN; PROVIDED THAT IF AN
INSURER HAS ESTABLISHED DIFFERENT STANDARD TERMS AND CONDITIONS FOR MAIL
ORDER PHARMACIES AND NON-MAIL ORDER RETAIL PHARMACIES, THE TERM STANDARD
TERMS AND CONDITIONS SHALL MEAN THE STANDARD TERMS AND CONDITIONS THAT
WERE IN EFFECT ON JUNE FIRST, TWO THOUSAND FIFTEEN FOR NON-MAIL ORDER
RETAIL PHARMACIES, AND PROVIDED FURTHER THAT ANY SUCH STANDARD TERMS AND
CONDITIONS THAT REQUIRE:
(I) CONSULTATION WITH A PHARMACIST SHALL NOT REQUIRE SUCH CONSULTATION
BE AVAILABLE AT NON-MAIL ORDER PHARMACIES OUTSIDE OF SUCH PHARMACY'S
REGULAR HOURS OF OPERATION AND SHALL REQUIRE MAIL ORDER PHARMACIES TO
PROVIDE SUCH CONSULTATION TWENTY-FOUR HOURS A DAY, SEVEN DAYS A WEEK;
(II) SPECIFIC STORAGE SIZE FOR PRESCRIPTION DRUGS REQUIRING SPECIAL
HANDLING, SUCH AS REFRIGERATION, SHALL BE BASED ON THE CONTRACTING PHAR-
MACY'S DISPENSING EXPERIENCE AND SHALL NOT REQUIRE A PHARMACY TO
INCREASE ITS STORAGE SPACE WHEN IT HAS NOT BEEN ESTABLISHED THAT SUCH
PHARMACY'S PRESCRIPTION VOLUME REQUIRES SUCH INCREASED STORAGE; AND
(III) SPECIFIC STORAGE SPACE FOR PRESCRIPTION DRUGS THAT DO NOT
REQUIRE SPECIAL HANDLING SHALL BASE SUCH REQUIREMENTS ON THE CONTRACTING
PHARMACY'S PHYSICAL SIZE AND DISPENSING EXPERIENCE AND SHALL NOT REQUIRE
A PHARMACY TO INCREASE ITS STORAGE SPACE WHEN IT HAS NOT BEEN ESTAB-
LISHED THAT SUCH PHARMACY'S PRESCRIPTION VOLUME REQUIRES SUCH INCREASED
STORAGE.
(B) Any insurer delivering a group or blanket policy or issuing a
group or blanket policy for delivery in this state that provides cover-
age for prescription drugs shall permit each insured to fill any covered
prescription that may be obtained at a network participating mail order
or other non-retail pharmacy, at the insured's option, at a network
participating non-mail order retail pharmacy provided that the network
participating non-mail order retail pharmacy [agrees in advance, through
a contractual network agreement,] to the same reimbursement amount[, as
well as the same applicable terms and conditions,] AND STANDARD TERMS
AND CONDITIONS that the insurer has established for the network partic-
ipating [mail order or other non-retail pharmacy] PHARMACIES. In such a
A. 2810 7
case, the policy shall not impose a co-payment fee or other condition,
INCLUDING REQUIRING MONTHLY REFILLS OF A PRESCRIPTION THAT WAS WRITTEN
FOR AND MAY BE FILLED FOR MORE THAN A THIRTY-DAY SUPPLY, on any insured
who elects to purchase drugs from a network participating non-mail order
retail pharmacy which is not also imposed on insureds electing to
purchase drugs from a network participating mail order or other non-re-
tail pharmacy; provided, however, that the provisions of this section
shall not supersede the terms of a collective bargaining agreement or
apply to a policy that is the result of a collective bargaining agree-
ment between an employer and a recognized or certified employee organ-
ization.
(C) ANY POLICY THAT PROVIDES COVERAGE FOR PRESCRIPTION DRUGS SHALL, IN
ADDITION TO THE STANDARD TERMS AND CONDITIONS, REQUIRE MAIL ORDER PHAR-
MACIES TO REPLACE DISPENSED PRESCRIPTION DRUGS FOR WHICH THE MAIL OR
CARRIER SERVICE HAS PROOF OF DELIVERY THAT HAVE NOT BEEN RECEIVED BY THE
INSURED, OR ARE SPOILED OR DAMAGED, PROVIDED THAT IN THE CASE OF A
PRESCRIPTION DRUG THAT HAS NOT BEEN RECEIVED BY THE INSURED, THE POLICY
MAY REQUIRE THAT THE INSURED PROVIDE PROOF OF THEFT IN THE FORM OF A
FILED POLICE REPORT REPORTING THE THEFT AND IN THE CASE OF A DAMAGED OR
SPOILED PRESCRIPTION DRUG, THE POLICY MAY REQUIRE THAT THE DAMAGED
PRESCRIPTION DRUG BE RETURNED TO THE MAIL ORDER PHARMACY WITH THE COST
TO BE BORNE BY SUCH PHARMACY, AND PROVIDED FURTHER THAT SUCH UNRECEIVED,
SPOILED OR DAMAGED PRESCRIPTION DRUG SHALL BE REPLACED BEFORE RECEIPT OF
THE POLICE REPORT OR THE SPOILED OR DAMAGED PRESCRIPTION DRUG, AS THE
CASE MAY BE. IF SUCH REQUIRED POLICE REPORT IS NOT PROVIDED OR THE
DAMAGED OR SPOILED PRESCRIPTION DRUG IS NOT RETURNED, THE POLICY MAY
REQUIRE THE INSURED TO REIMBURSE THE POLICY FOR THE COST OF THE
PRESCRIPTION DRUG AND, NOTWITHSTANDING THE FORGOING, WHEN AN INSURED WHO
WAS PREVIOUSLY REQUIRED TO REIMBURSE THE PLAN FOR A DISPENSED
PRESCRIPTION DRUG THAT WAS NOT RECEIVED BY THE INSURED, OR WAS DAMAGED
OR SPOILED, THE POLICY MAY REFUSE TO REPLACE SUCH PRESCRIPTION DRUG FOR
SUCH INSURED UNTIL SUCH INSURED HAS PROVIDED THE PLAN WITH THE REQUIRED
POLICE REPORT OR RETURNED THE SPOILED OR DAMAGED PRESCRIPTION DRUG.
REPLACEMENT OF A PRESCRIPTION DRUG PURSUANT TO THIS SUBPARAGRAPH SHALL
NOT BE LIMITED TO A SPECIFIC NUMBER OF OCCURRENCES DURING A CONTRACT
YEAR.
§ 4. Paragraph 4 of subsection (s) of section 4303 of the insurance
law, as amended by chapter 10 of the laws of 2012, is amended to read as
follows:
(4) (A) DEFINITION. FOR THE PURPOSE OF THIS PARAGRAPH:
(I) "SAME REIMBURSEMENT AMOUNT" SHALL MEAN THAT ANY COVERAGE DESCRIBED
UNDER SUBPARAGRAPH (B) OF THIS PARAGRAPH SHALL PROVIDE THE SAME BENCH-
MARK INDEX, INCLUDING THE SAME AVERAGE WHOLESALE PRICE, MAXIMUM ALLOW-
ABLE COST AND NATIONAL PRESCRIPTION DRUG CODES TO REIMBURSE ALL PHARMA-
CIES PARTICIPATING IN THE INSURANCE NETWORK REGARDLESS OF WHETHER A
PHARMACY IS A MAIL ORDER PHARMACY OR A NON-MAIL ORDER PHARMACY.
(II) "MAIL ORDER PHARMACY" SHALL MEAN A PHARMACY WHOSE PRIMARY BUSI-
NESS IS TO RECEIVE PRESCRIPTIONS BY MAIL, TELEFAX OR THROUGH ELECTRONIC
SUBMISSIONS AND TO DISPENSE MEDICATION TO PATIENTS THROUGH THE USE OF
THE UNITED STATES MAIL OR OTHER COMMON OR CONTRACT CARRIER SERVICES AND
PROVIDES ANY CONSULTATION WITH PATIENTS ELECTRONICALLY RATHER THAN FACE-
TO-FACE.
(III) "STANDARD TERMS AND CONDITIONS" SHALL MEAN THE CONTRACTUAL TERMS
AND CONDITIONS APPLICABLE TO ALL NETWORK PARTICIPATING PHARMACIES THAT
WERE IN EFFECT ON JUNE FIRST, TWO THOUSAND FIFTEEN; PROVIDED THAT IF AN
INSURER HAD ESTABLISHED DIFFERENT STANDARD TERMS AND CONDITIONS FOR MAIL
A. 2810 8
ORDER PHARMACIES AND NON-MAIL ORDER RETAIL PHARMACIES, THE TERM STANDARD
TERMS AND CONDITIONS SHALL MEAN THE STANDARD TERMS AND CONDITIONS THAT
WERE IN EFFECT ON JUNE FIRST, TWO THOUSAND FIFTEEN FOR NON-MAIL ORDER
RETAIL PHARMACIES, AND PROVIDED FURTHER THAT ANY SUCH STANDARD TERMS AND
CONDITIONS THAT REQUIRE:
(I) CONSULTATION WITH A PHARMACIST SHALL NOT REQUIRE SUCH CONSULTATION
BE AVAILABLE AT NON-MAIL ORDER PHARMACIES OUTSIDE OF SUCH PHARMACY'S
REGULAR HOURS OF OPERATION AND SHALL REQUIRE MAIL ORDER PHARMACIES TO
PROVIDE SUCH CONSULTATION TWENTY-FOUR HOURS A DAY, SEVEN DAYS A WEEK;
(II) SPECIFIC STORAGE SPACE FOR PRESCRIPTION DRUGS REQUIRE SPECIAL
HANDLING, SUCH AS REFRIGERATION, SHALL BE BASED ON THE CONTRACTING PHAR-
MACY'S DISPENSING EXPERIENCE AND SHALL NOT REQUIRE A PHARMACY TO
INCREASE ITS STORAGE SPACE WHEN IT HAS NOT BEEN ESTABLISHED THAT SUCH
PHARMACY'S PRESCRIPTION VOLUME REQUIRES SUCH INCREASED STORAGE; AND
(III) SPECIFIC STORAGE SPACE FOR PRESCRIPTION DRUGS THAT DO NOT
REQUIRE SPECIAL HANDLING SHALL BE BASED ON ON THE CONTRACTING PHARMACY'S
PHYSICAL SIZE AND DISPENSING EXPERIENCE AND SHALL NOT REQUIRE A PHARMACY
TO INCREASE ITS STORAGE SPACE WHEN IT HAS NOT BEEN ESTABLISHED THAT SUCH
PHARMACY'S PRESCRIPTION VOLUME REQUIRES SUCH INCREASED STORAGE.
(B) Every contract issued by a medical expense indemnity corporation,
a hospital service corporation or a health services corporation that
provides coverage for prescription fertility drugs and requires or
permits prescription drugs to be purchased through a network participat-
ing mail order or other non-retail pharmacy shall provide the same
coverage for prescription fertility drugs AND SHALL NOT LIMIT THE SUPPLY
THAT MAY BE DISPENSED TO A THIRTY-DAY SUPPLY when such drugs are
purchased from a network participating non-mail order retail pharmacy
provided that the network participating non-mail order retail pharmacy
agrees [in advance, through a contractual network agreement,] to the
same reimbursement amount[, as well as the same applicable terms and
conditions,] AND STANDARD TERMS AND CONDITIONS that the corporation has
established for the network participating [mail order or other non-re-
tail pharmacy] PHARMACIES. In such case, the contract shall not impose
any fee, co-payment, co-insurance, deductible or other condition,
INCLUDING REQUIRING MONTHLY REFILLS OF A PRESCRIPTION THAT WAS WRITTEN
FOR AND MAY BE FILLED FOR MORE THAN A THIRTY-DAY SUPPLY, on any covered
person who does not elect to purchase prescription fertility drugs
through a network participating mail order or other non-retail pharmacy;
provided, however, that the provisions of this section shall not super-
sede the terms of a collective bargaining agreement or apply to a
contract that is the result of a collective bargaining agreement between
an employer and a recognized or certified employee organization.
(C) ANY POLICY THAT PROVIDES COVERAGE FOR PRESCRIPTION FERTILITY DRUGS
SHALL, IN ADDITION TO THE STANDARD TERMS AND CONDITIONS, REQUIRE MAIL
ORDER PHARMACIES TO REPLACE DISPENSED PRESCRIPTION FERTILITY DRUGS FOR
WHICH THE MAIL OR CARRIER SERVICE HAS PROOF OF DELIVERY THAT HAVE BEEN
NOT RECEIVED BY THE INSURED, OR ARE SPOILED OR DAMAGED, PROVIDED THAT IN
THE CASE OF A PRESCRIPTION FERTILITY DRUG THAT HAS NOT BEEN RECEIVED BY
THE INSURED, THE POLICY MAY REQUIRE THAT THE INSURED PROVIDE PROOF OF
THEFT IN THE FORM OF A FILED POLICE REPORT REPORTING THE THEFT AND IN
THE CASE OF A DAMAGED OR SPOILED PRESCRIPTION FERTILITY DRUG, THE POLICY
MAY REQUIRE THAT THE DAMAGED PRESCRIPTION FERTILITY DRUG BE RETURNED TO
THE MAIL ORDER PHARMACY WITH THE COST TO BE BORNE BY SUCH PHARMACY, AND
PROVIDED FURTHER THAT SUCH UNRECEIVED, SPOILED OR DAMAGED PRESCRIPTION
FERTILITY DRUG SHALL BE REPLACED BEFORE RECEIPT OF THE POLICE REPORT OR
THE SPOILED OR DAMAGED PRESCRIPTION FERTILITY DRUG, AS THE CASE MAY BE.
A. 2810 9
IF SUCH REQUIRED POLICE REPORT IS NOT PROVIDED OR THE DAMAGED OR SPOILED
PRESCRIPTION FERTILITY DRUG IS NOT RETURNED, THE POLICY MAY REQUIRE THE
INSURED TO REIMBURSE THE POLICY FOR THE COST OF THE PRESCRIPTION FERTIL-
ITY DRUG AND, NOTWITHSTANDING THE FORGOING, WHEN AN INSURED WHO WAS
PREVIOUSLY REQUIRED TO REIMBURSE THE PLAN FOR A DISPENSED PRESCRIPTION
FERTILITY DRUG THAT WAS NOT RECEIVED BY THE INSURED, OR WAS DAMAGED OR
SPOILED, THE POLICY MAY REFUSE TO REPLACE SUCH PRESCRIPTION FERTILITY
DRUG FOR SUCH INSURED UNTIL SUCH INSURED HAS PROVIDED THE PLAN WITH THE
REQUIRED POLICE REPORT OR RETURNED THE SPOILED OR DAMAGED PRESCRIPTION
FERTILITY DRUG. REPLACEMENT OF A PRESCRIPTION FERTILITY DRUG PURSUANT TO
THIS PARAGRAPH SHALL NOT BE LIMITED TO A SPECIFIC NUMBER OF OCCURRENCES
DURING A CONTRACT YEAR.
§ 5. Subsection (kk) of section 4303 of the insurance law, as amended
by chapter 11 of the laws of 2012 and as relettered by section 55 of
part D of chapter 56 of the laws of 2013, is amended to read as follows:
(kk) (1) DEFINITIONS. FOR THE PURPOSE OF THIS SUBSECTION:
(A) "SAME REIMBURSEMENT AMOUNT" SHALL MEAN THAT ANY COVERAGE DESCRIBED
UNDER PARAGRAPH TWO OF THIS SUBSECTION SHALL PROVIDE THE SAME BENCHMARK
INDEX, INCLUDING THE SAME AVERAGE WHOLESALE PRICE, MAXIMUM ALLOWABLE
COST AND NATIONAL PRESCRIPTION DRUG CODES TO REIMBURSE ALL PHARMACIES
PARTICIPATING IN THE INSURANCE NETWORK REGARDLESS OF WHETHER A PHARMACY
IS A MAIL ORDER PHARMACY OR A NON-MAIL ORDER PHARMACY.
(B) "MAIL ORDER PHARMACY" SHALL MEAN A PHARMACY WHOSE PRIMARY BUSINESS
IS TO RECEIVE PRESCRIPTIONS BY MAIL, TELEFAX OR THROUGH ELECTRONIC
SUBMISSIONS AND TO DISPENSE MEDICATION TO PATIENTS THROUGH THE USE OF
THE UNITED STATES MAIL OR OTHER COMMON OR CONTRACT CARRIER SERVICES AND
PROVIDES ANY CONSULTATION WITH PATIENTS ELECTRONICALLY RATHER THAN FACE-
TO-FACE.
(C) "STANDARD TERMS AND CONDITIONS" SHALL MEAN THE CONTRACTUAL TERMS
AND CONDITIONS APPLICABLE TO ALL NETWORK PARTICIPATING PHARMACIES THAT
WERE IN EFFECT ON JUNE FIRST, TWO THOUSAND FIFTEEN; PROVIDED THAT IF AN
INSURER HAS ESTABLISHED DIFFERENT STANDARD TERMS AND CONDITIONS FOR MAIL
ORDER PHARMACIES AND NON-MAIL ORDER RETAIL PHARMACIES, THE TERM STANDARD
TERMS AND CONDITIONS SHALL MEAN THE STANDARD TERMS AND CONDITIONS THAT
WERE IN EFFECT ON JUNE FIRST, TWO THOUSAND FIFTEEN FOR NON-MAIL ORDER
RETAIL PHARMACIES, AND PROVIDED FURTHER THAT ANY SUCH STANDARD TERMS AND
CONDITIONS THAT REQUIRE:
(I) CONSULTATION WITH A PHARMACIST SHALL NOT REQUIRE SUCH CONSULTATION
BE AVAILABLE AT NON-MAIL ORDER PHARMACIES OUTSIDE OF SUCH PHARMACY'S
REGULAR HOURS OF OPERATION AND SHALL REQUIRE MAIL ORDER PHARMACIES TO
PROVIDE SUCH CONSULTATION TWENTY-FOUR HOURS A DAY, SEVEN DAYS A WEEK;
(II) SPECIFIC STORAGE SIZE FOR PRESCRIPTION DRUGS REQUIRING SPECIAL
HANDLING, SUCH AS REFRIGERATION, SHALL BE BASED ON THE CONTRACTING PHAR-
MACY'S DISPENSING EXPERIENCE AND SHALL NOT REQUIRE A PHARMACY TO
INCREASE ITS STORAGE SPACE WHEN IT HAS NOT BEEN ESTABLISHED THAT SUCH
PHARMACY'S PRESCRIPTION VOLUME REQUIRES SUCH INCREASED STORAGE; AND
(III) SPECIFIC STORAGE SPACE FOR PRESCRIPTION DRUGS THAT DO NOT
REQUIRE SPECIAL HANDLING SHALL BE BASED ON THE CONTRACTING PHARMACY'S
PHYSICAL SIZE AND DISPENSING EXPERIENCE AND SHALL NOT REQUIRE A PHARMACY
TO INCREASE ITS STORAGE SPACE WHEN IT HAS NOT BEEN ESTABLISHED THAT SUCH
PHARMACY'S PRESCRIPTION VOLUME REQUIRES SUCH INCREASED STORAGE.
(2) Any contract issued by a medical expense indemnity corporation, a
hospital service corporation or a health services corporation that
provides coverage for prescription drugs shall permit each covered
person to fill any covered prescription that may be obtained at a
network participating mail order or other non-retail pharmacy, at the
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covered person's option, at a network participating non-mail order
retail pharmacy provided that the network participating non-mail order
retail pharmacy agrees [in advance, through a contractual network agree-
ment,] to the same reimbursement amount[, as well as the same applicable
terms and conditions,] AND STANDARD TERMS AND CONDITIONS that the corpo-
ration has established for the network participating [mail order or
other non-retail pharmacy] PHARMACIES. In such a case, the contract
shall not impose a copayment fee or other condition, INCLUDING REQUIRING
MONTHLY REFILLS OF A PRESCRIPTION THAT WAS WRITTEN FOR AND MAY BE FILLED
FOR MORE THAN A THIRTY-DAY SUPPLY, on any covered person who elects to
purchase drugs from a network participating non-mail order retail phar-
macy which is not also imposed on covered persons electing to purchase
drugs from a network participating mail order or other non-retail phar-
macy; provided, however, that the provisions of this section shall not
supersede the terms of a collective bargaining agreement or apply to a
contract that is the result of a collective bargaining agreement between
an employer and a recognized or certified employee organization.
(3) ANY POLICY THAT PROVIDES COVERAGE FOR PRESCRIPTION DRUGS SHALL, IN
ADDITION TO THE STANDARD TERMS AND CONDITIONS, REQUIRE MAIL ORDER PHAR-
MACIES TO REPLACE DISPENSED PRESCRIPTION DRUGS FOR WHICH THE MAIL OR
CARRIER SERVICE HAS PROOF OF DELIVERY THAT HAVE NOT BEEN RECEIVED BY THE
INSURED, OR ARE SPOILED OR DAMAGED, PROVIDED THAT IN THE CASE OF A
PRESCRIPTION DRUG THAT HAS NOT BEEN RECEIVED BY THE INSURED, THE POLICY
MAY REQUIRE THAT THE INSURED PROVIDE PROOF OF THEFT IN THE FORM OF A
FILED POLICE REPORT REPORTING THEFT AND IN THE CASE OF A DAMAGED OR
SPOILED PRESCRIPTION DRUG, THE POLICY MAY REQUIRE THAT THE DAMAGED
PRESCRIPTION DRUG BE RETURNED TO THE MAIL ORDER PHARMACY WITH THE COST
TO BE BORNE BY SUCH PHARMACY, AND PROVIDED FURTHER THAT SUCH UNRECEIVED,
SPOILED OR DAMAGED PRESCRIPTION DRUG SHALL BE REPLACED BEFORE RECEIPT OF
THE POLICE REPORT OR THE SPOILED OR DAMAGED PRESCRIPTION DRUG, AS THE
CASE MAY BE. IF SUCH REQUIRED POLICE REPORT IS NOT PROVIDED OR THE
DAMAGED OR SPOILED PRESCRIPTION DRUG IS NOT RETURNED, THE POLICY MAY
REQUIRE THE INSURED TO REIMBURSE THE POLICY FOR THE COST OF THE
PRESCRIPTION DRUG AND, NOTWITHSTANDING THE FORGOING, WHEN AN INSURED WHO
WAS PREVIOUSLY REQUIRED TO REIMBURSE THE PLAN FOR A DISPENSED
PRESCRIPTION DRUG THAT WAS NOT RECEIVED BY THE INSURED, OR WAS DAMAGED
OR SPOILED, THE POLICY MAY REFUSE TO REPLACE SUCH PRESCRIPTION DRUG FOR
SUCH INSURED UNTIL SUCH INSURED HAS PROVIDED THE PLAN WITH THE REQUIRED
POLICE REPORT OR RETURNED THE SPOILED OR DAMAGED PRESCRIPTION DRUG.
REPLACEMENT OF A PRESCRIPTION DRUG PURSUANT TO THIS PARAGRAPH SHALL NOT
BE LIMITED TO A SPECIFIC NUMBER OF OCCURRENCES DURING A CONTRACT YEAR.
§ 6. Severability. If any clause, sentence, paragraph, section or part
of this act shall be adjudged by any court of competent jurisdiction to
be invalid, the judgement shall not affect, impair, or invalidate the
remainder thereof, but shall be confined in its operation to the clause,
sentence, paragraph, section or part thereof directly involved in the
controversy in which the judgement shall have been rendered.
§ 7. This act shall take effect immediately.