S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   6244
 
                        2019-2020 Regular Sessions
 
                             I N  S E N A T E
 
                               May 29, 2019
                                ___________
 
 Introduced by Sen. GOUNARDES -- read twice and ordered printed, and when
   printed to be committed 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:
 
   Section  1.  The insurance law is amended by adding a new section 4806
 to read as follows:
   § 4806. ACCESS TO APPROPRIATE DRUGS AT  REASONABLE  PRICES;  FORMULARY
 EXCEPTIONS;  STANDING  PRIOR  AUTHORIZATION  REQUIREMENT. (A) AN INSURER
 OFFERING A PRESCRIPTION DRUG BENEFIT WITH A  FORMULARY  OF  APPROVED  OR
 PREFERRED  DRUGS  SHALL  ESTABLISH  A  PROCEDURE  BY WHICH IT DETERMINES
 WHETHER A FORMULARY DRUG PROVIDES APPROPRIATE  THERAPEUTIC  BENEFITS  TO
 MEET  THE  PARTICULAR  HEALTH  CARE  NEEDS OF AN INSURED. IF THE INSURER
 DETERMINES THAT NO FORMULARY DRUG PROVIDES APPROPRIATE THERAPEUTIC BENE-
 FITS TO MEET THE PARTICULAR HEALTH CARE NEEDS OF AN INSURED, THE INSURER
 SHALL COVER THE COST OF AN OFF-FORMULARY DRUG FOR THAT  INSURED,  AT  NO
 ADDITIONAL  COST  TO THE INSURED BEYOND WHAT THE INSURED WOULD OTHERWISE
 PAY FOR A PREFERRED BRAND NAME DRUG ON THE FORMULARY. THE DETERMINATIONS
 WHETHER A DRUG PROVIDES APPROPRIATE THERAPEUTIC BENEFITS AND  WHETHER  A
 NON-FORMULARY DRUG IS NECESSARY TO MEET THE PARTICULAR HEALTH CARE NEEDS
 OF  THE  INSURED  ARE UTILIZATION REVIEW DECISIONS AND ARE REVIEWABLE IN
 ACCORDANCE WITH ARTICLE FORTY-NINE OF THIS CHAPTER,  INCLUDING  EXTERNAL
 APPEAL.
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD07324-01-9
              

 S. 6244                             2
 
   (B)  (1)  FOR  PURPOSES OF THIS SECTION, "PRIOR AUTHORIZATION REQUIRE-
 MENT" MEANS ANY PRACTICE IMPLEMENTED BY AN INSURER IN WHICH COVERAGE  OF
 A  PRESCRIPTION  DRUG  OR DEVICE IS DEPENDENT UPON A COVERED PERSON OR A
 HEALTH CARE PRACTITIONER OBTAINING APPROVAL FROM THE  INSURER  PRIOR  TO
 THE  SERVICE,  DEVICE, OR DRUG BEING PERFORMED, RECEIVED, OR PRESCRIBED,
 AS APPLICABLE. "PRIOR AUTHORIZATION" INCLUDES PROSPECTIVE OR UTILIZATION
 REVIEW PROCEDURES CONDUCTED PRIOR TO PROVIDING A DRUG OR DEVICE.
   (2) AN INSURER WHICH  REQUIRES  PRIOR  AUTHORIZATIONS  FOR  PARTICULAR
 PRESCRIPTION  DRUGS  SHALL  HAVE  A PROCEDURE BY WHICH AN INSURED WHO IS
 BEING PRESCRIBED SUCH DRUG FOR A CHRONIC CONDITION MAY OBTAIN A STANDING
 PRIOR AUTHORIZATION FOR A DRUG FOR THE LESSER OF THE FOLLOWING FROM  THE
 DATE  OF  THE  APPROVAL:  (I) TWELVE MONTHS; OR (II) THE LAST DAY OF THE
 COVERED PERSON'S ELIGIBILITY UNDER THE POLICY OR PLAN.
   (3) AS A CONDITION OF SUCH STANDING PRIOR AUTHORIZATION, IF  ACCORDING
 TO  THE  AVAILABLE MEDICAL AND SCIENTIFIC EVIDENCE THE PATIENT'S CHRONIC
 CONDITION IS LIKELY TO CHANGE DURING THE STANDING REFERRAL  PERIOD,  THE
 INSURER  OR  HEALTH PLAN MAY REQUIRE THE PRESCRIBING HEALTH CARE PRACTI-
 TIONER TO CERTIFY TO THE INSURER, NOT MORE FREQUENTLY THAN ON A QUARTER-
 LY BASIS, THAT THE PATIENT'S CHRONIC CONDITION  HAS  NOT  CHANGED  MATE-
 RIALLY WITH RESPECT TO THE NEED FOR THE PRESCRIPTION.
   (4)  A  TWELVE-MONTH STANDING PRIOR AUTHORIZATION PROVIDED UNDER PARA-
 GRAPH TWO OF THIS SUBSECTION DOES NOT APPLY TO AND IS NOT  REQUIRED  FOR
 ANY OF THE FOLLOWING:
   (I)  MEDICATIONS  THAT HAVE A TYPICAL COURSE OF ADMINISTRATION OF LESS
 THAN ONE YEAR OR FOR WHICH AVAILABLE MEDICAL OR SCIENTIFIC EVIDENCE DOES
 NOT SUPPORT A TWELVE-MONTH PERIOD OF USE, IN  WHICH  CASE  THE  STANDING
 PRIOR AUTHORIZATION PERIOD SHALL BE THE TYPICAL COURSE OF ADMINISTRATION
 OR  THE  PERIOD  OF USE SUPPORTED BY THE AVAILABLE MEDICAL OR SCIENTIFIC
 EVIDENCE;
   (II) MEDICATIONS THAT REQUIRE AN INITIAL  TRIAL  PERIOD  TO  DETERMINE
 EFFECTIVENESS  AND  TOLERABILITY,  EXCEPT THAT AFTER SUCH TRIAL PERIOD A
 ONE-YEAR, OR GREATER, PRIOR AUTHORIZATION PERIOD WILL BE GIVEN; AND
   (III) MEDICATIONS THAT ARE SCHEDULE II CONTROLLED SUBSTANCE OR A SCHE-
 DULE III CONTROLLED SUBSTANCE CONTAINING HYDROCODONE.
   (5) FOR DRUGS USED TO TREAT ACUTE  CONDITIONS,  INSURERS  SHALL  GRANT
 STANDING PRIOR AUTHORIZATIONS FOR THE PERIOD THAT THE MEDICAL AND SCIEN-
 TIFIC  EVIDENCE  SHOWS  TO  BE  THE ANTICIPATED PERIOD FOR THE COURSE OF
 TREATMENT TO HAVE ITS INTENDED EFFECT.
   (6) THE STANDING PRIOR AUTHORIZATIONS PROVIDED FOR IN THIS SECTION ARE
 NO LONGER VALID AND AUTOMATICALLY TERMINATE  IF  THERE  ARE  CHANGES  TO
 FEDERAL  OR  STATE  LAWS  OR  FEDERAL  REGULATORY GUIDANCE OR COMPLIANCE
 INFORMATION FINDING THAT THE DRUG IN QUESTION IS NO LONGER  APPROVED  OR
 SAFE FOR THE PRESCRIBED PURPOSE.
   (7)  IF AN AB-RATED GENERIC DRUG THAT IS THERAPEUTICALLY EQUIVALENT TO
 THE DRUG SUBJECT TO A STANDING PRIOR  AUTHORIZATION  BECOMES  AVAILABLE,
 THE INSURER MAY SUBSTITUTE SUCH NEWLY RELEASED DRUG FOR THE DRUG SUBJECT
 TO THE STANDING PRIOR AUTHORIZATION, PROVIDED ADVANCE NOTICE IS GIVEN TO
 THE INSURED.
   (8)  THE DETERMINATION WHETHER THE DRUG IS BEING PRESCRIBED TO TREAT A
 CHRONIC CONDITION AND THE PERIOD OVER WHICH THE COURSE OF TREATMENT  FOR
 AN ACUTE CONDITION IS ANTICIPATED TO HAVE ITS INTENDED EFFECT ARE UTILI-
 ZATION  REVIEW  DECISIONS  AND ARE REVIEWABLE IN ACCORDANCE WITH ARTICLE
 FORTY-NINE OF THIS CHAPTER, INCLUDING EXTERNAL APPEAL.
   (C) (1) IF A FORMULARY DRUG BEING PRESCRIBED FOR AN INSURED IS REMOVED
 BY THE INSURER FROM ITS FORMULARY FOR REASONS OTHER THAN A DETERMINATION
 THAT THE APPROVAL FOR THE USE OF THAT DRUG HAS  BEEN  WITHDRAWN  BY  THE

 S. 6244                             3
 
 U.S.  FOOD  AND DRUG ADMINISTRATION, THE INSURER SHALL CONTINUE TO COVER
 THAT DRUG FOR THAT INSURED FOR A TRANSITIONAL PERIOD TO THE END  OF  THE
 PLAN  YEAR  AT THE SAME COPAYMENT AS CHARGED WHEN THE DRUG WAS ON FORMU-
 LARY.   THEREAFTER, THE INSURED MAY SEEK CONTINUED COVERAGE OF THE DRUG,
 IF APPROPRIATE, PURSUANT TO THE PROVISIONS OF  SUBSECTION  (A)  OF  THIS
 SECTION.
   (2)  IF  A  FORMULARY DRUG BEING PRESCRIBED FOR AN INSURED IS MOVED BY
 THE INSURER TO A HIGHER COST SHARING TIER IN ITS FORMULARY  FOR  REASONS
 OTHER  THAN  RELEASE  OF  AN  AB-RATED  GENERIC  DRUG, THE INSURER SHALL
 CONTINUE TO COVER THAT DRUG FOR THAT INSURED FOR A  TRANSITIONAL  PERIOD
 TO  THE  END  OF THE PLAN YEAR AT THE SAME COPAYMENT AS CHARGED WHEN THE
 DRUG WAS ON FORMULARY. THEREAFTER, THE INSURED MAY SEEK CONTINUED COVER-
 AGE  OF  THE  DRUG,  IF  APPROPRIATE,  PURSUANT  TO  THE  PROVISIONS  OF
 SUBSECTION (A) OF THIS SECTION.
   (3)  IF  AN INSURER THAT PROVIDES PRESCRIPTION DRUG COVERAGE ENROLLS A
 NEW INSURED WHO IS CURRENTLY BEING  PRESCRIBED  A  DRUG  FOR  A  CHRONIC
 HEALTH  CONDITION,  OR  AS PART OF AN ONGOING COURSE OF TREATMENT FOR AN
 ACUTE CONDITION, AND THAT DRUG IS NOT ON THE  INSURER'S  FORMULARY,  THE
 INSURER  SHALL COVER THAT DRUG FOR THAT INSURED AT NO ADDITIONAL COST TO
 THE INSURED BEYOND WHAT THE INSURED WOULD OTHERWISE PAY FOR A  PREFERRED
 BRAND  NAME  DRUG  ON THE FORMULARY, FOR A TRANSITIONAL PERIOD OF NINETY
 (90) DAYS FROM THE EFFECTIVE DATE OF ENROLLMENT. THE INSURED MUST ADHERE
 TO THE INSURER'S QUALITY  ASSURANCE  REQUIREMENTS  AND  PROVIDE  TO  THE
 INSURER  NECESSARY  MEDICAL  INFORMATION RELATED TO THE PRESCRIPTION AND
 OTHERWISE ADHERE TO THE INSURER'S POLICIES AND PROCEDURES INCLUDING, BUT
 NOT LIMITED TO PROCEDURES REGARDING OBTAINING  PRE-AUTHORIZATION  AND  A
 TREATMENT  PLAN  APPROVED  BY  THE  INSURER.  IN  NO  EVENT  SHALL  THIS
 SUBSECTION BE CONSTRUED TO REQUIRE AN INSURER TO  PROVIDE  COVERAGE  FOR
 BENEFITS  NOT  OTHERWISE  COVERED.  THE  TRANSITIONAL  PERIOD  DOES  NOT
 PRECLUDE THE INSURED FROM SEEKING CONTINUED COVERAGE  OF  THE  DRUG,  IF
 APPROPRIATE,  PURSUANT  TO  THE  PROVISIONS  OF  SUBSECTION  (A) OF THIS
 SECTION.
   § 2. The public health law is amended by adding a new  section  4406-h
 to read as follows:
   §  4406-H. ACCESS TO APPROPRIATE DRUGS AT REASONABLE PRICES; FORMULARY
 EXCEPTIONS; STANDING PRIOR AUTHORIZATION REQUIREMENT. 1. A HEALTH  MAIN-
 TENANCE  ORGANIZATION OFFERING A PRESCRIPTION DRUG BENEFIT WITH A FORMU-
 LARY OF APPROVED OR PREFERRED DRUGS SHALL HAVE A PROCEDURE BY  WHICH  IT
 DETERMINES  WHETHER  A  FORMULARY  DRUG PROVIDES APPROPRIATE THERAPEUTIC
 BENEFITS TO MEET THE PARTICULAR HEALTH CARE NEEDS OF AN ENROLLEE. IF THE
 HEALTH  MAINTENANCE  ORGANIZATION  DETERMINES  THAT  NO  FORMULARY  DRUG
 PROVIDES  APPROPRIATE THERAPEUTIC BENEFITS TO MEET THE PARTICULAR HEALTH
 CARE NEEDS OF AN ENROLLEE, THE  HEALTH  MAINTENANCE  ORGANIZATION  SHALL
 COVER  THE  COST OF AN OFF-FORMULARY DRUG FOR THAT ENROLLEE, AT NO ADDI-
 TIONAL COST TO THE ENROLLEE BEYOND WHAT THE ENROLLEE WOULD OTHERWISE PAY
 FOR A PREFERRED BRAND NAME DRUG ON  THE  FORMULARY.  THE  DETERMINATIONS
 WHETHER  A  DRUG PROVIDES APPROPRIATE THERAPEUTIC BENEFITS AND WHETHER A
 NON-FORMULARY DRUG IS NECESSARY TO MEET THE PARTICULAR HEALTH CARE NEEDS
 OF THE INSURED ARE UTILIZATION REVIEW DECISIONS AND  ARE  REVIEWABLE  IN
 ACCORDANCE  WITH  ARTICLE FORTY-NINE OF THIS CHAPTER, INCLUDING EXTERNAL
 APPEAL.
   2. (A) FOR PURPOSES OF THIS SECTION, "PRIOR AUTHORIZATION REQUIREMENT"
 MEANS ANY PRACTICE IMPLEMENTED BY A HEALTH MAINTENANCE  ORGANIZATION  IN
 WHICH  COVERAGE  OF  A  PRESCRIPTION  DRUG OR DEVICE IS DEPENDENT UPON A
 COVERED PERSON OR A HEALTH CARE PRACTITIONER OBTAINING APPROVAL FROM THE
 HEALTH MAINTENANCE ORGANIZATION PRIOR TO THE SERVICE,  DEVICE,  OR  DRUG

 S. 6244                             4
 
 BEING PERFORMED, RECEIVED, OR PRESCRIBED, AS APPLICABLE. "PRIOR AUTHORI-
 ZATION"  INCLUDES PROSPECTIVE OR UTILIZATION REVIEW PROCEDURES CONDUCTED
 PRIOR TO PROVIDING A DRUG OR DEVICE.
   (B)  A  HEALTH  MAINTENANCE ORGANIZATION WHICH REQUIRES PRIOR AUTHORI-
 ZATIONS FOR PARTICULAR PRESCRIPTION DRUGS  SHALL  HAVE  A  PROCEDURE  BY
 WHICH AN ENROLLEE WHO IS BEING PRESCRIBED SUCH DRUG FOR A CHRONIC CONDI-
 TION MAY OBTAIN A STANDING PRIOR AUTHORIZATION FOR A DRUG FOR THE LESSER
 OF THE FOLLOWING FROM THE DATE OF THE APPROVAL:  (I) TWELVE MONTHS; (II)
 THE LAST DAY OF THE ENROLLEE'S ELIGIBILITY UNDER THE POLICY OR PLAN.
   (C)  AS A CONDITION OF SUCH STANDING PRIOR AUTHORIZATION, IF ACCORDING
 TO THE AVAILABLE MEDICAL AND SCIENTIFIC EVIDENCE THE ENROLLEE'S  CHRONIC
 CONDITION  IS  LIKELY TO CHANGE DURING THE STANDING REFERRAL PERIOD, THE
 INSURER OR HEALTH PLAN MAY REQUIRE THE PRESCRIBING HEALTH  CARE  PRACTI-
 TIONER  TO  CERTIFY  TO  THE  HEALTH  MAINTENANCE ORGANIZATION, NOT MORE
 FREQUENTLY THAN ON A QUARTERLY BASIS, THAT THE ENROLLEE'S CHRONIC CONDI-
 TION HAS NOT CHANGED  MATERIALLY  WITH  RESPECT  TO  THE  NEED  FOR  THE
 PRESCRIPTION.
   (D) A TWELVE-MONTH STANDING PRIOR AUTHORIZATION PROVIDED UNDER SUBPAR-
 AGRAPH (I) OF PARAGRAPH (B) OF THIS SUBDIVISION DOES NOT APPLY TO AND IS
 NOT REQUIRED FOR ANY OF THE FOLLOWING:
   (I)  MEDICATIONS  THAT HAVE A TYPICAL COURSE OF ADMINISTRATION OF LESS
 THAN ONE YEAR OR FOR WHICH AVAILABLE MEDICAL OR SCIENTIFIC EVIDENCE DOES
 NOT SUPPORT A TWELVE-MONTH PERIOD OF USE, IN  WHICH  CASE  THE  STANDING
 PRIOR AUTHORIZATION PERIOD SHALL BE THE TYPICAL COURSE OF ADMINISTRATION
 OR  THE  PERIOD  OF USE SUPPORTED BY THE AVAILABLE MEDICAL OR SCIENTIFIC
 EVIDENCE;
   (II) MEDICATIONS THAT REQUIRE AN INITIAL  TRIAL  PERIOD  TO  DETERMINE
 EFFECTIVENESS  AND  TOLERABILITY,  EXCEPT THAT AFTER SUCH TRIAL PERIOD A
 ONE-YEAR, OR GREATER, PRIOR AUTHORIZATION PERIOD WILL BE GIVEN; AND
   (III) MEDICATIONS THAT ARE SCHEDULE II CONTROLLED SUBSTANCE OR A SCHE-
 DULE III CONTROLLED SUBSTANCE CONTAINING HYDROCODONE.
   (E) FOR DRUGS USED TO TREAT ACUTE  CONDITIONS,  INSURERS  SHALL  GRANT
 STANDING PRIOR AUTHORIZATIONS FOR THE PERIOD THAT THE MEDICAL AND SCIEN-
 TIFIC  EVIDENCE  SHOWS  TO  BE  THE ANTICIPATED PERIOD FOR THE COURSE OF
 TREATMENT TO HAVE ITS INTENDED EFFECT.
   (F) THE STANDING PRIOR AUTHORIZATIONS PROVIDED FOR IN THIS SECTION ARE
 NO LONGER VALID AND AUTOMATICALLY TERMINATE  IF  THERE  ARE  CHANGES  TO
 FEDERAL  OR  STATE  LAWS  OR  FEDERAL  REGULATORY GUIDANCE OR COMPLIANCE
 INFORMATION FINDING THAT THE DRUG IN QUESTION IS NO LONGER  APPROVED  OR
 SAFE FOR THE PRESCRIBED PURPOSE.
   (G)  IF AN AB-RATED GENERIC DRUG THAT IS THERAPEUTICALLY EQUIVALENT TO
 THE DRUG SUBJECT TO A STANDING PRIOR  AUTHORIZATION  BECOMES  AVAILABLE,
 THE  HEALTH  MAINTENANCE ORGANIZATION MAY SUBSTITUTE SUCH NEWLY RELEASED
 DRUG FOR THE DRUG SUBJECT TO THE STANDING PRIOR AUTHORIZATION,  PROVIDED
 ADVANCE NOTICE IS GIVEN TO THE ENROLLEE.
   (H)  THE DETERMINATION WHETHER THE DRUG IS BEING PRESCRIBED TO TREAT A
 CHRONIC CONDITION AND THE PERIOD OVER WHICH THE COURSE OF TREATMENT  FOR
 AN ACUTE CONDITION IS ANTICIPATED TO HAVE ITS INTENDED EFFECT ARE UTILI-
 ZATION  REVIEW  DECISIONS  AND ARE REVIEWABLE IN ACCORDANCE WITH ARTICLE
 FORTY-NINE OF THIS CHAPTER, INCLUDING EXTERNAL APPEAL.
   3. (A) IF A FORMULARY DRUG BEING PRESCRIBED FOR AN ENROLLEE IS REMOVED
 BY THE HEALTH MAINTENANCE ORGANIZATION FROM ITS  FORMULARY  FOR  REASONS
 OTHER  THAN  A  DETERMINATION THAT THE APPROVAL FOR THE USE OF THAT DRUG
 HAS BEEN WITHDRAWN BY THE U.S.  FOOD AND DRUG ADMINISTRATION, THE HEALTH
 MAINTENANCE ORGANIZATION SHALL CONTINUE TO  COVER  THAT  DRUG  FOR  THAT
 ENROLLEE  FOR  A  TRANSITIONAL PERIOD TO THE END OF THE PLAN YEAR AT THE

 S. 6244                             5
 
 SAME COPAYMENT AS CHARGED WHEN THE DRUG WAS  ON  FORMULARY.  THEREAFTER,
 THE  ENROLLEE  MAY  SEEK CONTINUED COVERAGE OF THE DRUG, IF APPROPRIATE,
 PURSUANT TO THE PROVISIONS OF SUBDIVISION ONE OF THIS SECTION.
   (B)  IF  A  FORMULARY DRUG BEING PRESCRIBED FOR AN INSURED IS MOVED BY
 THE HEALTH MAINTENANCE ORGANIZATION TO A HIGHER COST SHARING TIER IN ITS
 FORMULARY FOR REASONS OTHER THAN RELEASE OF AN  AB-RATED  GENERIC  DRUG,
 THE  HEALTH  MAINTENANCE  ORGANIZATION SHALL CONTINUE TO COVER THAT DRUG
 FOR THAT ENROLLEE FOR A TRANSITIONAL PERIOD TO THE END OF THE PLAN  YEAR
 AT THE SAME COPAYMENT AS CHARGED WHEN THE DRUG WAS ON FORMULARY.  THERE-
 AFTER,  THE  ENROLLEE MAY SEEK CONTINUED COVERAGE OF THE DRUG, IF APPRO-
 PRIATE, PURSUANT TO THE PROVISIONS OF SUBDIVISION ONE OF THIS SECTION.
   (C) IF A HEALTH MAINTENANCE ORGANIZATION  THAT  PROVIDES  PRESCRIPTION
 DRUG COVERAGE ENROLLS A NEW ENROLLEE WHO IS CURRENTLY BEING PRESCRIBED A
 DRUG  FOR A CHRONIC HEALTH CONDITION, OR AS PART OF AN ONGOING COURSE OF
 TREATMENT FOR AN ACUTE CONDITION, AND THAT DRUG IS  NOT  ON  THE  HEALTH
 MAINTENANCE  ORGANIZATION'S  FORMULARY, THE HEALTH MAINTENANCE ORGANIZA-
 TION SHALL COVER THAT DRUG FOR THAT ENROLLEE AT NO  ADDITIONAL  COST  TO
 THE  ENROLLEE  BEYOND  WHAT  THE  ENROLLEE  WOULD  OTHERWISE  PAY  FOR A
 PREFERRED BRAND NAME DRUG ON THE FORMULARY, FOR A TRANSITIONAL PERIOD OF
 NINETY (90) DAYS FROM THE EFFECTIVE DATE  OF  ENROLLMENT.  THE  ENROLLEE
 MUST  ADHERE  TO THE HEALTH MAINTENANCE ORGANIZATION'S QUALITY ASSURANCE
 REQUIREMENTS AND PROVIDE TO THE HEALTH MAINTENANCE  ORGANIZATION  NECES-
 SARY  MEDICAL  INFORMATION  RELATED  TO  THE  PRESCRIPTION AND OTHERWISE
 ADHERE TO THE HEALTH MAINTENANCE ORGANIZATION'S POLICIES AND  PROCEDURES
 INCLUDING, BUT NOT LIMITED TO PROCEDURES REGARDING OBTAINING PRE-AUTHOR-
 IZATION  AND  A TREATMENT PLAN APPROVED BY THE HEALTH MAINTENANCE ORGAN-
 IZATION. IN NO EVENT SHALL THIS SUBDIVISION BE CONSTRUED  TO  REQUIRE  A
 HEALTH  MAINTENANCE  ORGANIZATION  TO  PROVIDE COVERAGE FOR BENEFITS NOT
 OTHERWISE COVERED.  THE TRANSITIONAL PERIOD DOES NOT PRECLUDE THE ENROL-
 LEE FROM SEEKING CONTINUED COVERAGE OF THE DRUG, IF APPROPRIATE,  PURSU-
 ANT TO THE PROVISIONS OF SUBDIVISION ONE OF THIS SECTION.
   §  3.  Section  4903  of  the insurance law is amended by adding a new
 subsection (i) to read as follows:
   (I) (1) EACH HEALTH PLAN SHALL MAKE  AVAILABLE  TO  ALL  PARTICIPATING
 HEALTH  CARE  PROVIDERS  ON ITS WEB SITE OR PROVIDER PORTAL A LISTING OF
 ITS PRIOR AUTHORIZATION REQUIREMENTS, INCLUDING SPECIFIC INFORMATION  OR
 DOCUMENTATION THAT A PROVIDER MUST SUBMIT IN ORDER FOR THE PRIOR AUTHOR-
 IZATION REQUEST TO BE CONSIDERED COMPLETE.
   (2)  EACH HEALTH PLAN SHALL MAKE AVAILABLE ON ITS WEB SITE INFORMATION
 ABOUT THE POLICIES, CONTRACTS, OR AGREEMENTS OFFERED BY IT THAT  CLEARLY
 IDENTIFIES SPECIFIC SERVICES, DRUGS, OR DEVICES TO WHICH A PRIOR AUTHOR-
 IZATION REQUIREMENT EXISTS.
   (3)  EACH  HEALTH  PLAN  SHALL  GIVE  THIRTY (30) DAYS ADVANCE WRITTEN
 NOTICE TO PARTICIPATING PROVIDERS OF ANY CHANGES IN PRIOR  AUTHORIZATION
 REQUIREMENTS.  EACH HEALTH PLAN SHALL ALSO GIVE THIRTY (30) DAYS ADVANCE
 WRITTEN NOTICE TO PLAN PARTICIPANTS OF ANY  CHANGES  IN  PRIOR  AUTHORI-
 ZATION REQUIREMENTS WITH RESPECT TO ANY SERVICES, DRUGS OR DEVICES WHICH
 SUCH PARTICIPANT IS CURRENTLY BEING PRESCRIBED OR HAS BEEN PRESCRIBED IN
 THE PRECEDING YEAR.
   §  4. Section 4903 of the public health law is amended by adding a new
 subdivision 9 to read as follows:
   9. (A) EACH HEALTH PLAN SHALL  MAKE  AVAILABLE  TO  ALL  PARTICIPATING
 HEALTH  CARE  PROVIDERS  ON ITS WEB SITE OR PROVIDER PORTAL A LISTING OF
 ITS PRIOR AUTHORIZATION REQUIREMENTS, INCLUDING SPECIFIC INFORMATION  OR
 DOCUMENTATION THAT A PROVIDER MUST SUBMIT IN ORDER FOR THE PRIOR AUTHOR-
 IZATION REQUEST TO BE CONSIDERED COMPLETE.

 S. 6244                             6
 
   (B)  EACH HEALTH PLAN SHALL MAKE AVAILABLE ON ITS WEB SITE INFORMATION
 ABOUT THE POLICIES, CONTRACTS, OR AGREEMENTS OFFERED BY IT THAT  CLEARLY
 IDENTIFIES SPECIFIC SERVICES, DRUGS, OR DEVICES TO WHICH A PRIOR AUTHOR-
 IZATION REQUIREMENT EXISTS.
   (C)  EACH  HEALTH  PLAN  SHALL  GIVE  THIRTY (30) DAYS ADVANCE WRITTEN
 NOTICE TO PARTICIPATING PROVIDERS OF ANY CHANGES IN PRIOR  AUTHORIZATION
 REQUIREMENTS.  EACH HEALTH PLAN SHALL ALSO GIVE THIRTY (30) DAYS ADVANCE
 WRITTEN NOTICE TO PLAN PARTICIPANTS OF ANY  CHANGES  IN  PRIOR  AUTHORI-
 ZATION REQUIREMENTS WITH RESPECT TO ANY SERVICES, DRUGS OR DEVICES WHICH
 SUCH PARTICIPANT IS CURRENTLY BEING PRESCRIBED OR HAS BEEN PRESCRIBED IN
 THE PRECEDING YEAR.
   § 5. Subsection (b) of section 4910 of the insurance law is amended by
 adding a new paragraph 5 to read as follows:
   (5)  (A)  THE INSURED HAS HAD A DRUG PRESCRIPTION DENIED ON THE GROUND
 THAT IT IS NOT ON THE HEALTH CARE PLAN'S FORMULARY, AND THAT THE  HEALTH
 CARE PLAN HAS A COVERED DRUG ON THE FORMULARY WHICH IS EFFECTIVE TO MEET
 THE PARTICULAR HEALTH CARE NEEDS OF AN INSURED; AND
   (B)  THE INSURED'S ATTENDING PHYSICIAN, WHO SHALL BE A LICENSED PHYSI-
 CIAN OR OTHER HEALTH CARE PROVIDER QUALIFIED TO PRESCRIBE DRUGS TO TREAT
 THE INSURED FOR THE HEALTH  SERVICE  SOUGHT,  CERTIFIES  THAT  AVAILABLE
 FORMULARY  DRUGS  ARE  NOT  SUFFICIENTLY EFFECTIVE TO MEET THE INSURED'S
 HEALTH NEEDS, OR ARE OTHERWISE  CONTRAINDICATED  FOR  THE  INSURED,  AND
 RECOMMENDS  AN  OFF-FORMULARY  DRUG  THAT WILL BE EFFECTIVE TO TREAT THE
 INSURED.
   § 6. Subdivision 2 of section 4910 of the public health law is amended
 by adding a new paragraph (e) to read as follows:
   (E) (I) THE ENROLLEE HAS HAD A DRUG PRESCRIPTION DENIED ON THE  GROUND
 THAT  IT  IS NOT ON THE HEALTH MAINTENANCE ORGANIZATION'S FORMULARY, AND
 THAT THE HEALTH MAINTENANCE ORGANIZATION  HAS  A  COVERED  DRUG  ON  THE
 FORMULARY WHICH IS EFFECTIVE TO MEET THE PARTICULAR HEALTH CARE NEEDS OF
 AN ENROLLEE; AND
   (II)  THE  ENROLLEE'S  ATTENDING  PHYSICIAN,  WHO  SHALL BE A LICENSED
 PHYSICIAN OR OTHER HEALTH CARE PROVIDER QUALIFIED TO PRESCRIBE DRUGS  TO
 TREAT  THE  INSURED FOR THE HEALTH SERVICE SOUGHT, CERTIFIES THAT AVAIL-
 ABLE  FORMULARY  DRUGS  ARE  NOT  SUFFICIENTLY  EFFECTIVE  TO  MEET  THE
 ENROLLEE'S HEALTH NEEDS, OR ARE OTHERWISE CONTRAINDICATED FOR THE ENROL-
 LEE,  AND  RECOMMENDS  AN  OFF-FORMULARY  DRUG THAT WILL BE EFFECTIVE TO
 TREAT THE ENROLLEE.
   § 7. Paragraph 4 of subsection (b) of section 4914  of  the  insurance
 law is amended by adding a new subparagraph (E) to read as as follows:
   (E)  FOR  EXTERNAL  APPEALS  REQUESTED  PURSUANT  TO PARAGRAPH FIVE OF
 SUBSECTION (B) OF SECTION FOUR THOUSAND NINE HUNDRED TEN OF  THIS  TITLE
 RELATING  TO  AN  OFF-FORMULARY  DRUG  DENIAL, THE EXTERNAL APPEAL AGENT
 SHALL REVIEW THE UTILIZATION REVIEW AGENT'S FINAL ADVERSE  DETERMINATION
 AND,  IN  ACCORDANCE  WITH  THE  PROVISIONS  OF THIS TITLE, SHALL MAKE A
 DETERMINATION AS TO WHETHER THE NON-FORMULARY DRUG SHALL BE  COVERED  BY
 THE HEALTH PLAN; PROVIDED THAT SUCH DETERMINATION SHALL:
   (I)  BE CONDUCTED ONLY BY ONE OR A GREATER ODD NUMBER OF CLINICAL PEER
 REVIEWERS;
   (II) BE ACCOMPANIED BY A WRITTEN STATEMENT:
   (I) THAT THE OFF-FORMULARY DRUG PRESCRIPTION SHALL BE COVERED  BY  THE
 HEALTH  CARE PLAN EITHER WHEN THE REVIEWER OR A MAJORITY OF THE PANEL OF
 REVIEWERS DETERMINES, UPON REVIEW OF THE AVAILABLE MEDICAL AND SCIENTIF-
 IC EVIDENCE, THE FORMULARY DRUG DEEMED SUFFICIENT  BY  THE  HEALTH  PLAN
 WILL  NOT BE AS EFFECTIVE IN ADDRESSING THE INSURED'S HEALTH PROBLEM FOR
 WHICH A DRUG HAS BEEN PRESCRIBED AS THE OFF-FORMULARY DRUG PRESCRIBED BY

 S. 6244                             7
 
 THE TREATING PHYSICIAN OR OTHERWISE BE APPROPRIATE TO MEET  THE  PARTIC-
 ULAR HEALTH CARE NEEDS OF THE INSURED, WHICH IS MORE LIKELY TO PROVIDE A
 BENEFICIAL CLINICAL OUTCOME; OR
   (II) UPHOLDING THE HEALTH PLAN'S DENIAL OF COVERAGE.
   § 8. Subdivision 2 of section 4914 of the public health law is amended
 by adding a new paragraph (e) to read as follows:
   (E) FOR EXTERNAL APPEALS REQUESTED PURSUANT TO PARAGRAPH (E) OF SUBDI-
 VISION  TWO  OF SECTION FORTY-NINE HUNDRED TEN OF THIS TITLE RELATING TO
 AN OFF-FORMULARY DRUG DENIAL, THE EXTERNAL APPEAL AGENT SHALL REVIEW THE
 UTILIZATION REVIEW AGENT'S FINAL ADVERSE DETERMINATION AND,  IN  ACCORD-
 ANCE WITH THE PROVISIONS OF THIS TITLE, SHALL MAKE A DETERMINATION AS TO
 WHETHER  THE  NON-FORMULARY  DRUG SHALL BE COVERED BY THE HEALTH MAINTE-
 NANCE ORGANIZATION; PROVIDED THAT SUCH DETERMINATION SHALL:
   (I) BE CONDUCTED ONLY BY ONE OR A GREATER ODD NUMBER OF CLINICAL  PEER
 REVIEWERS;
   (II) BE ACCOMPANIED BY A WRITTEN STATEMENT:
   (1)  THAT  THE OFF-FORMULARY DRUG PRESCRIPTION SHALL BE COVERED BY THE
 HEALTH MAINTENANCE ORGANIZATION EITHER WHEN THE REVIEWER OR  A  MAJORITY
 OF  THE  PANEL  OF  REVIEWERS  DETERMINES,  UPON REVIEW OF THE AVAILABLE
 MEDICAL AND SCIENTIFIC EVIDENCE, THE FORMULARY DRUG DEEMED SUFFICIENT BY
 THE HEALTH MAINTENANCE ORGANIZATION WILL NOT BE AS EFFECTIVE IN ADDRESS-
 ING THE ENROLLEE'S HEALTH PROBLEM FOR WHICH A DRUG HAS  BEEN  PRESCRIBED
 AS THE OFF-FORMULARY DRUG PRESCRIBED BY THE TREATING PHYSICIAN OR OTHER-
 WISE  BE  APPROPRIATE  TO  MEET  THE PARTICULAR HEALTH CARE NEEDS OF THE
 ENROLLEE, WHICH IS MORE LIKELY TO PROVIDE A BENEFICIAL CLINICAL OUTCOME;
 OR
   (2) UPHOLDING THE HEALTH MAINTENANCE ORGANIZATION'S DENIAL  OF  COVER-
 AGE.
   §  9.  The  opening  paragraph  of  paragraph  28 of subsection (i) of
 section 3216 of the insurance law, as added by chapter 589 of  the  laws
 of  2011,  is  designated subparagraph (A) and a new subparagraph (B) is
 added to read as follows:
   (B) NOTWITHSTANDING ANY OTHER PROVISION OF THIS PARAGRAPH, IF A  PRES-
 CRIBER,  AFTER CONSULTING WITH THE INSURER REGARDING THE APPROPRIATENESS
 OF MAIL ORDER DELIVERY GIVEN: (I) THE RESIDENCE OR DELIVERY LOCATION  OF
 THE  INSURED; (II) THE MEDICAL CONDITION OF THE INSURED; (III) THE STOR-
 AGE REQUIREMENTS OF THE DRUG; (IV) THE AVAILABILITY OF  THE  INSURED  TO
 RECEIVE  THE  PRESCRIPTION;  OR  (V) THE INSURED'S ABILITY TO COMPREHEND
 PHARMACEUTICAL GUIDANCE AND SUPPORT OVER THE TELEPHONE, DETERMINES  THAT
 A DRUG AS PRESCRIBED ON AN INDIVIDUAL BASIS IS MOST APPROPRIATELY FILLED
 AT A RETAIL LOCATION, PROVIDED THAT AN IN-NETWORK RETAIL PHARMACY OF THE
 PATIENT'S  CHOOSING  AGREES TO THE SAME REIMBURSEMENT AMOUNT AND IS ABLE
 TO FILL THE PRESCRIPTION, THE PRESCRIBER'S DETERMINATION SHALL BE FINAL.
   § 10. The opening paragraph of  paragraph  18  of  subsection  (1)  of
 section  3221  of the insurance law is designated subparagraph (A) and a
 new subparagraph (B) is added to read as follows:
   (B) NOTWITHSTANDING ANY OTHER PROVISION OF THIS PARAGRAPH, IF A  PRES-
 CRIBER,  AFTER CONSULTING WITH THE INSURER REGARDING THE APPROPRIATENESS
 OF MAIL ORDER DELIVERY GIVEN: (I) THE RESIDENCE OR DELIVERY LOCATION  OF
 THE  INSURED; (II) THE MEDICAL CONDITION OF THE INSURED; (III) THE STOR-
 AGE REQUIREMENTS OF THE DRUG; (IV) THE AVAILABILITY OF  THE  INSURED  TO
 RECEIVE  THE  PRESCRIPTION;  OR  (V) THE INSURED'S ABILITY TO COMPREHEND
 PHARMACEUTICAL GUIDANCE AND SUPPORT OVER THE TELEPHONE, DETERMINES  THAT
 A DRUG AS PRESCRIBED ON AN INDIVIDUAL BASIS IS MOST APPROPRIATELY FILLED
 AT A RETAIL LOCATION, PROVIDED THAT AN IN-NETWORK RETAIL PHARMACY OF THE

 S. 6244                             8
 
 PATIENT'S  CHOOSING  AGREES TO THE SAME REIMBURSEMENT AMOUNT AND IS ABLE
 TO FILL THE PRESCRIPTION, THE PRESCRIBER'S DETERMINATION SHALL BE FINAL.
   §  11. The opening paragraph of subsection (kk) of section 4303 of the
 insurance law is designated paragraph 1 and a new paragraph 2  is  added
 to read as follows:
   (2) NOTWITHSTANDING ANY OTHER PROVISION OF THIS SUBSECTION, IF A PRES-
 CRIBER,  AFTER CONSULTING WITH THE INSURER REGARDING THE APPROPRIATENESS
 OF MAIL ORDER DELIVERY GIVEN: (A) THE RESIDENCE OR DELIVERY LOCATION  OF
 THE COVERED PERSON; (B) THE MEDICAL CONDITION OF THE COVERED PERSON; (C)
 THE  STORAGE  REQUIREMENTS  OF  THE  DRUG;  (D)  THE AVAILABILITY OF THE
 COVERED PERSON TO RECEIVE THE PRESCRIPTION; OR (E) THE COVERED  PERSON'S
 ABILITY TO COMPREHEND PHARMACEUTICAL GUIDANCE AND SUPPORT OVER THE TELE-
 PHONE,  DETERMINES  THAT  A DRUG AS PRESCRIBED ON AN INDIVIDUAL BASIS IS
 MOST APPROPRIATELY FILLED AT A RETAIL LOCATION, PROVIDED THAT AN IN-NET-
 WORK RETAIL PHARMACY OF  THE  PATIENT'S  CHOOSING  AGREES  TO  THE  SAME
 REIMBURSEMENT   AMOUNT  AND  IS  ABLE  TO  FILL  THE  PRESCRIPTION,  THE
 PRESCRIBER'S DETERMINATION SHALL BE FINAL.
   § 12. The insurance law is amended by adding a new section  3224-d  to
 read as follows:
   §  3224-D. PRESCRIPTION SYNCHRONIZATION. (A) EVERY INDIVIDUAL OR GROUP
 HEALTH INSURANCE POLICY PROVIDING PRESCRIPTION DRUG COVERAGE WHEN APPLI-
 CABLE TO PERMIT SYNCHRONIZATION SHALL PERMIT AND APPLY A DAILY  PRORATED
 COST-SHARING RATE TO PRESCRIPTIONS THAT ARE DISPENSED BY A NETWORK PHAR-
 MACY  FOR  LESS  THAN  A  THIRTY DAY SUPPLY, WHEN IT IS AGREED AMONG THE
 COVERED INDIVIDUAL, A HEALTH CARE PRACTITIONER, AND  A  PHARMACIST  THAT
 SYNCHRONIZATION OF MULTIPLE PRESCRIPTIONS FOR THE TREATMENT OF A CHRONIC
 ILLNESS  IS  IN  THE  BEST  INTEREST  OF  THE COVERED INDIVIDUAL FOR THE
 MANAGEMENT OR TREATMENT OF THAT CHRONIC ILLNESS PROVIDED THAT ALL OF THE
 FOLLOWING APPLY:
   (1) THE MEDICATIONS ARE COVERED BY THE POLICY OR PLAN;
   (2) THE MEDICATIONS ARE USED FOR TREATMENT AND MANAGEMENT  OF  CHRONIC
 CONDITIONS THAT ARE SUBJECT TO REFILLS;
   (3)  THE  MEDICATIONS  ARE NOT A SCHEDULE II CONTROLLED SUBSTANCE OR A
 SCHEDULE III CONTROLLED SUBSTANCE CONTAINING HYDROCODONE;
   (4) THE MEDICATIONS MEET ALL PRIOR AUTHORIZATION CRITERIA SPECIFIC  TO
 MEDICATIONS AT THE TIME OF THE SYNCHRONIZATION REQUEST;
   (5) THE MEDICATIONS ARE OF A FORMULATION THAT CAN BE EFFECTIVELY SPLIT
 OVER REQUIRED SHORT FILL PERIODS TO ACHIEVE SYNCHRONIZATION; AND
   (6)  THE  MEDICATIONS DO NOT HAVE QUANTITY LIMITS OR DOSE OPTIMIZATION
 CRITERIA OR REQUIREMENTS THAT WOULD BE VIOLATED IN FULFILLING SYNCHRONI-
 ZATION.
   (B)  NO  INDIVIDUAL  OR  GROUP  HEALTH  INSURANCE   POLICY   PROVIDING
 PRESCRIPTION  DRUG  COVERAGE SHALL DENY COVERAGE FOR THE DISPENSING OF A
 MEDICATION FOR PARTIAL FILL WHEN IT IS FOR PURPOSES OF SYNCHRONIZING THE
 PATIENT'S MEDICATIONS. WHEN APPLICABLE TO PERMIT SYNCHRONIZATION,  EVERY
 INDIVIDUAL  OR  GROUP  HEALTH  INSURANCE POLICY MUST ALLOW A PHARMACY TO
 OVERRIDE ANY DENIAL  CODES  INDICATING  THAT  A  PRESCRIPTION  IS  BEING
 REFILLED TOO SOON FOR THE PURPOSES OF MEDICATION SYNCHRONIZATION.
   (C)  DISPENSING  FEES  FOR  PARTIALLY FILLED OR REFILLED PRESCRIPTIONS
 SHALL BE PAID IN FULL FOR EACH PRESCRIPTION DISPENSED, REGARDLESS OF ANY
 PRO-RATED COPAY FOR THE BENEFICIARY OR FEE PAID FOR ALIGNMENT SERVICES.
   (D) NOTHING IN THIS SECTION SHALL BE DEEMED  TO  REQUIRE  HEALTH  CARE
 PRACTITIONERS  AND  PHARMACISTS TO SYNCHRONIZE THE REFILLING OF MULTIPLE
 PRESCRIPTIONS FOR A COVERED INDIVIDUAL.

 S. 6244                             9
 
   (E) THE REQUIREMENTS OF THIS SECTION SHALL APPLY ONLY  ONCE  FOR  EACH
 PRESCRIPTION  DRUG  SUBJECT  TO  MEDICATION  SYNCHRONIZATION EXCEPT WHEN
 EITHER OF THE FOLLOWING OCCURS:
   (1)  THE  PRESCRIBER CHANGES THE DOSAGE OR FREQUENCY OF ADMINISTRATION
 OF THE PRESCRIPTION DRUG SUBJECT TO A MEDICATION SYNCHRONIZATION; OR
   (2) THE PRESCRIBER PRESCRIBES A DIFFERENT DRUG.
   § 13. The insurance law is amended by adding a new section  4303-a  to
 read as follows:
   §  4303-A.  PRESCRIPTION  SYNCHRONIZATION.  (A) EVERY HOSPITAL SERVICE
 CORPORATION AND HEALTH SERVICE CORPORATION PROVIDING  PRESCRIPTION  DRUG
 COVERAGE  WHEN  APPLICABLE  TO  PERMIT  SYNCHRONIZATION SHALL PERMIT AND
 APPLY A DAILY PRORATED  COST-SHARING  RATE  TO  PRESCRIPTIONS  THAT  ARE
 DISPENSED  BY A NETWORK PHARMACY FOR LESS THAN A THIRTY DAY SUPPLY, WHEN
 IT IS AGREED AMONG THE COVERED INDIVIDUAL, A HEALTH  CARE  PRACTITIONER,
 AND  A PHARMACIST THAT SYNCHRONIZATION OF MULTIPLE PRESCRIPTIONS FOR THE
 TREATMENT OF A CHRONIC ILLNESS IS IN THE BEST INTEREST  OF  THE  COVERED
 INDIVIDUAL  FOR  THE  MANAGEMENT  OR  TREATMENT  OF THAT CHRONIC ILLNESS
 PROVIDED THAT ALL OF THE FOLLOWING APPLY:
   (1) THE MEDICATIONS ARE COVERED BY THE POLICY OR PLAN;
   (2) THE MEDICATIONS ARE USED FOR TREATMENT AND MANAGEMENT  OF  CHRONIC
 CONDITIONS THAT ARE SUBJECT TO REFILLS;
   (3)  THE  MEDICATIONS  ARE NOT A SCHEDULE II CONTROLLED SUBSTANCE OR A
 SCHEDULE III CONTROLLED SUBSTANCE CONTAINING HYDROCODONE;
   (4) THE MEDICATIONS MEET ALL PRIOR AUTHORIZATION CRITERIA SPECIFIC  TO
 MEDICATIONS AT THE TIME OF THE SYNCHRONIZATION REQUEST;
   (5) THE MEDICATIONS ARE OF A FORMULATION THAT CAN BE EFFECTIVELY SPLIT
 OVER REQUIRED SHORT FILL PERIODS TO ACHIEVE SYNCHRONIZATION; AND
   (6)  THE  MEDICATIONS DO NOT HAVE QUANTITY LIMITS OR DOSE OPTIMIZATION
 CRITERIA OR REQUIREMENTS THAT WOULD BE VIOLATED IN FULFILLING SYNCHRONI-
 ZATION.
   (B) NO HOSPITAL SERVICE  CORPORATION  OR  HEALTH  SERVICE  CORPORATION
 PROVIDING  PRESCRIPTION  DRUG  COVERAGE  SHALL  DENY  COVERAGE  FOR  THE
 DISPENSING OF A MEDICATION FOR PARTIAL FILL WHEN IT IS FOR  PURPOSES  OF
 SYNCHRONIZING  THE  PATIENT'S  MEDICATIONS.  WHEN  APPLICABLE  TO PERMIT
 SYNCHRONIZATION, EVERY HOSPITAL SERVICE CORPORATION  OR  HEALTH  SERVICE
 CORPORATION  PROVIDING  PRESCRIPTION DRUG COVERAGE MUST ALLOW A PHARMACY
 TO OVERRIDE ANY DENIAL CODES INDICATING THAT  A  PRESCRIPTION  IS  BEING
 REFILLED TOO SOON FOR THE PURPOSES OF MEDICATION SYNCHRONIZATION.
   (C)  DISPENSING  FEES  FOR  PARTIALLY FILLED OR REFILLED PRESCRIPTIONS
 SHALL BE PAID IN FULL FOR EACH PRESCRIPTION DISPENSED, REGARDLESS OF ANY
 PRO-RATED COPAY FOR THE BENEFICIARY OR FEE PAID FOR ALIGNMENT SERVICES.
   (D) NOTHING IN THIS SECTION SHALL BE DEEMED  TO  REQUIRE  HEALTH  CARE
 PRACTITIONERS  AND  PHARMACISTS TO SYNCHRONIZE THE REFILLING OF MULTIPLE
 PRESCRIPTIONS FOR A COVERED INDIVIDUAL.
   (E) THE REQUIREMENTS OF THIS SECTION SHALL APPLY ONLY  ONCE  FOR  EACH
 PRESCRIPTION  DRUG  SUBJECT  TO  MEDICATION  SYNCHRONIZATION EXCEPT WHEN
 EITHER OF THE FOLLOWING OCCURS:
   (1) THE PRESCRIBER CHANGES THE DOSAGE OR FREQUENCY  OF  ADMINISTRATION
 OF THE PRESCRIPTION DRUG SUBJECT TO A MEDICATION SYNCHRONIZATION; OR
   (2) THE PRESCRIBER PRESCRIBES A DIFFERENT DRUG.
   §  14.  Subdivision  9  of section 367-a of the social services law is
 amended by adding a new paragraph (i) to read as follows:
   (I) (I) THE  DEPARTMENT  OF  HEALTH  SHALL  ESTABLISH  A  PROGRAM  FOR
 SYNCHRONIZATION  OF MEDICATIONS WHEN IT IS AGREED AMONG THE RECIPIENT, A
 PROVIDER AND A PHARMACIST THAT SYNCHRONIZATION OF MULTIPLE PRESCRIPTIONS
 FOR THE TREATMENT OF A CHRONIC ILLNESS IS IN THE BEST  INTEREST  OF  THE

 S. 6244                            10
 
 PATIENT  FOR  THE  MANAGEMENT OR TREATMENT OF A CHRONIC ILLNESS PROVIDED
 THAT THE MEDICATIONS:
   (A) ARE COVERED BY THE DEPARTMENT OF HEALTH PURSUANT TO THIS TITLE;
   (B)  ARE  USED FOR TREATMENT AND MANAGEMENT OF CHRONIC CONDITIONS THAT
 ARE SUBJECT TO REFILLS;
   (C) ARE NOT A SCHEDULE II  CONTROLLED  SUBSTANCE  OR  A  SCHEDULE  III
 CONTROLLED SUBSTANCE CONTAINING HYDROCODONE;
   (D)  MEET ALL PRIOR AUTHORIZATION CRITERIA SPECIFIC TO THE MEDICATIONS
 AT THE TIME OF THE SYNCHRONIZATION REQUEST;
   (E) ARE OF A FORMULATION THAT CAN BE EFFECTIVELY SPLIT  OVER  REQUIRED
 SHORT FILL PERIODS TO ACHIEVE SYNCHRONIZATION; AND
   (F)  DO  NOT  HAVE  QUANTITY  LIMITS  OR DOSE OPTIMIZATION CRITERIA OR
 REQUIREMENTS THAT WOULD BE VIOLATED IN FULFILLING SYNCHRONIZATION.
   (II) THE DEPARTMENT OF HEALTH SHALL NOT DENY COVERAGE FOR THE DISPENS-
 ING OF A MEDICATION BY A NETWORK PHARMACY FOR A PARTIAL SUPPLY  WHEN  IT
 IS  FOR  THE  PURPOSE  OF  SYNCHRONIZING THE PATIENT'S MEDICATIONS. WHEN
 APPLICABLE TO PERMIT SYNCHRONIZATION, THE  DEPARTMENT  OF  HEALTH  SHALL
 ALLOW  A  PHARMACY  TO  OVERRIDE  ANY  DENIAL  CODES  INDICATING  THAT A
 PRESCRIPTION IS BEING REFILLED TOO SOON FOR THE PURPOSES  OF  MEDICATION
 SYNCHRONIZATION.
   (III)  TO PERMIT SYNCHRONIZATION, THE DEPARTMENT OF HEALTH SHALL APPLY
 A PRORATED DAILY COST-SHARING RATE TO  ANY  MEDICATION  DISPENSED  BY  A
 NETWORK PHARMACY PURSUANT TO THIS SECTION.
   (IV)  THE  DISPENSING  FEE  PAID  TO  A NETWORK PHARMACY CONTRACTED TO
 PROVIDE SERVICES PURSUANT TO THIS SECTION FOR A PARTIAL  SUPPLY  ASSOCI-
 ATED  WITH  A MEDICATION SYNCHRONIZATION SHALL BE PAID IN FULL AND SHALL
 NOT BE PRORATED.
   (V) THE REQUIREMENTS OF THIS PARAGRAPH  APPLIES  ONLY  ONCE  FOR  EACH
 PRESCRIPTION  DRUG  SUBJECT  TO  MEDICATION  SYNCHRONIZATION EXCEPT WHEN
 EITHER OF THE FOLLOWING OCCURS:
   (A) THE PRESCRIBER CHANGES THE DOSAGE OR FREQUENCY  OF  ADMINISTRATION
 OF THE PRESCRIPTION DRUG SUBJECT TO A MEDICATION SYNCHRONIZATION; OR
   (B) THE PRESCRIBER PRESCRIBES A DIFFERENT DRUG.
   (VI)  NOTHING IN THIS PARAGRAPH SHALL BE DEEMED TO REQUIRE HEALTH CARE
 PRACTITIONERS AND PHARMACISTS TO SYNCHRONIZE THE REFILLING  OF  MULTIPLE
 PRESCRIPTIONS FOR A RECIPIENT.
   §  15.  Subdivision  4  of section 364-j of the social services law is
 amended by adding a new paragraph (w) to read as follows:
   (W) (I) THE DEPARTMENT  OF  HEALTH  OR  A  MANAGED  CARE  ORGANIZATION
 CONTRACTED  TO PROVIDE SERVICES PURSUANT TO THIS SECTION SHALL ESTABLISH
 A PROGRAM FOR SYNCHRONIZATION OF MEDICATIONS WHEN IT IS AGREED AMONG THE
 RECIPIENT, A PROVIDER AND A PHARMACIST THAT SYNCHRONIZATION OF  MULTIPLE
 PRESCRIPTIONS  FOR  THE  TREATMENT  OF  A CHRONIC ILLNESS IS IN THE BEST
 INTEREST OF THE PATIENT FOR THE MANAGEMENT OR  TREATMENT  OF  A  CHRONIC
 ILLNESS PROVIDED THAT THE MEDICATIONS:
   (A)  ARE  COVERED  BY MEDICAID SERVICES OR A MANAGED CARE ORGANIZATION
 CONTRACTED TO PROVIDE SERVICES PURSUANT TO THIS CHAPTER;
   (B) ARE USED FOR TREATMENT AND MANAGEMENT OF CHRONIC  CONDITIONS  THAT
 ARE SUBJECT TO REFILLS;
   (C)  ARE  NOT  A  SCHEDULE  II  CONTROLLED SUBSTANCE OR A SCHEDULE III
 CONTROLLED SUBSTANCE CONTAINING HYDROCODONE;
   (D) MEET ALL PRIOR AUTHORIZATION CRITERIA SPECIFIC TO THE  MEDICATIONS
 AT THE TIME OF THE SYNCHRONIZATION REQUEST;
   (E)  ARE  OF A FORMULATION THAT CAN BE EFFECTIVELY SPLIT OVER REQUIRED
 SHORT FILL PERIODS TO ACHIEVE SYNCHRONIZATION; AND

 S. 6244                            11
 
   (F) DO NOT HAVE QUANTITY  LIMITS  OR  DOSE  OPTIMIZATION  CRITERIA  OR
 REQUIREMENTS THAT WOULD BE VIOLATED IN FULFILLING SYNCHRONIZATION.
   (II)   THE  DEPARTMENT  OF  HEALTH  OR  A  MANAGED  CARE  ORGANIZATION
 CONTRACTED TO PROVIDE SERVICES UNDER THIS SECTION SHALL NOT DENY  COVER-
 AGE  FOR  THE  DISPENSING  OF  A  MEDICATION BY A NETWORK PHARMACY FOR A
 PARTIAL SUPPLY WHEN IT IS FOR THE PURPOSE OF SYNCHRONIZING THE PATIENT'S
 MEDICATIONS. WHEN APPLICABLE TO PERMIT SYNCHRONIZATION,  THE  DEPARTMENT
 OF  HEALTH OR A MANAGED CARE ORGANIZATION CONTRACTED TO PROVIDE SERVICES
 UNDER THIS TITLE SHALL ALLOW A PHARMACY  TO  OVERRIDE  ANY  DENIAL  CODE
 INDICATING  THAT  A  PRESCRIPTION  IS  BEING  REFILLED  TOO SOON FOR THE
 PURPOSES OF MEDICATION SYNCHRONIZATION.
   (III) TO PERMIT SYNCHRONIZATION, THE DEPARTMENT OF HEALTH OR A MANAGED
 CARE ORGANIZATION CONTRACTED TO PROVIDE SERVICES PURSUANT TO THIS  TITLE
 SHALL  APPLY  A  PRORATED  DAILY  COST-SHARING  RATE  TO  ANY MEDICATION
 DISPENSED BY A NETWORK PHARMACY PURSUANT TO THIS SECTION.
   (IV) THE DISPENSING FEE PAID  TO  A  NETWORK  PHARMACY  CONTRACTED  TO
 PROVIDE  SERVICES  PURSUANT TO THIS SECTION FOR A PARTIAL SUPPLY ASSOCI-
 ATED WITH A MEDICATION SYNCHRONIZATION SHALL BE PAID IN FULL  AND  SHALL
 NOT BE PRORATED.
   (V)  THE  REQUIREMENTS  OF  THIS  PARAGRAPH APPLIES ONLY ONCE FOR EACH
 PRESCRIPTION DRUG SUBJECT  TO  MEDICATION  SYNCHRONIZATION  EXCEPT  WHEN
 EITHER OF THE FOLLOWING OCCURS:
   (A)  THE  PRESCRIBER CHANGES THE DOSAGE OR FREQUENCY OF ADMINISTRATION
 OF THE PRESCRIPTION DRUG SUBJECT TO A MEDICATION SYNCHRONIZATION; OR
   (B) THE PRESCRIBER PRESCRIBES A DIFFERENT DRUG.
   (VI) NOTHING IN THIS PARAGRAPH SHALL BE DEEMED TO REQUIRE HEALTH  CARE
 PRACTITIONERS  AND  PHARMACISTS TO SYNCHRONIZE THE REFILLING OF MULTIPLE
 PRESCRIPTIONS FOR A COVERED INDIVIDUAL.
   § 16. Subsection (h) of section 4325 of the insurance law, as added by
 chapter 487 of the laws of 2010, is amended to read as follows:
   (h) (I) No corporation or insurer organized  or  licensed  under  this
 chapter which provides coverage for prescription drugs shall require, or
 enter into a contract which permits, a copayment which exceeds the usual
 and  customary  cost  of such prescribed drug OR WHICH EXCEEDS THE TOTAL
 PRICE PAID TO THE PHARMACY FOR SUCH PRESCRIBED DRUG  AFTER  THE  INSURED
 HAS MET THE ANNUAL DEDUCTIBLE REQUIREMENT.
   (II)  IN  DETERMINING ANY COINSURANCE AMOUNT REQUIRED TO BE PAID FOR A
 PRESCRIPTION DRUG, NO INSURER OR CORPORATION ORGANIZED UNDER THIS  CHAP-
 TER  SHALL  BASE ITS COMPUTATION ON A PRICE HIGHER THAN THE ACTUAL PRICE
 PAID BY THE PHARMACY FOR THE  DRUG,  TAKING  INTO  ACCOUNT  ANY  REBATES
 SPECIFIC  TO  THE DRUG. THE DEPARTMENT OF FINANCIAL SERVICES SHALL ISSUE
 REGULATIONS SETTING FORTH THE METHOD EACH INSURER OR CORPORATION  ORGAN-
 IZED  UNDER  THIS CHAPTER MUST USE TO DETERMINE THE ACTUAL PRICE PAID BY
 THE PHARMACY.
   (III) EACH INSURER OR CORPORATION LICENSED UNDER  THIS  ARTICLE  WHICH
 OFFERS  PRESCRIPTION  DRUG  COVERAGE MUST ITSELF OR THROUGH ITS PHARMACY
 BENEFIT MANAGER ISSUE A WRITTEN  EXPLANATION  OF  BENEFIT  FORM  TO  ITS
 ENROLLEES WITH RESPECT TO EACH PRESCRIPTION FILLED, CONTAINING ALL CATE-
 GORIES  OF  INFORMATION  REQUIRED  OF  EXPLANATION OF BENEFITS FORMS FOR
 MEDICAL BENEFITS.
   § 17. Subdivision 6 of section 6810 of the education law is amended by
 adding a new paragraph (b-1) to read as follows:
   (B-1) THE PRESCRIBER OR PHARMACIST SHALL INFORM THE PATIENT WHETHER HE
 OR SHE HAS PRESCRIBED OR SUBSTITUTED A DIFFERENT  GENERIC  DRUG  PRODUCT
 FROM  THE  GENERIC  DRUG  PRODUCT  THE  PATIENT HAS PREVIOUSLY RECEIVED.
 NOTIFICATION REQUIRED PURSUANT TO THIS PARAGRAPH SHALL BE PROVIDED  BOTH

 S. 6244                            12
 
 WRITTEN   AND   ORALLY,   CONTEMPORANEOUSLY  WITH  THE  FILLING  OF  THE
 PRESCRIPTION.
   §  18.  Section 6826-a of the education law is amended by adding a new
 subdivision 3 to read as follows:
   3. THE COPAYMENT AMOUNT SHALL NOT EXCEED THE TOTAL PRICE PAID  TO  THE
 PHARMACY  FOR THE PRESCRIBED DRUG, EXCEPT IN CASES WHERE THE INSURED HAS
 NOT MET THE ANNUAL DEDUCTIBLE REQUIREMENT. THE COPAYMENT  CHARGED  TO  A
 CONSUMER FOR A PRESCRIPTION DRUG SHALL NOT EXCEED THE AMOUNT WHICH WOULD
 BE CHARGED IF THE DRUG WERE PURCHASED WITHOUT INSURANCE COVERAGE.
   §  19.  Paragraph 1 of subsection (e) of section 3231 of the insurance
 law is amended by adding a new subparagraph (C) to read as follows:
   (C) AN INSURER SHALL ANNUALLY CERTIFY TO THE DEPARTMENT  THAT,  DURING
 THE  PRIOR  BENEFIT YEAR, THE INSURER MADE AVAILABLE TO ENROLLEES AT THE
 POINT OF SALE AT LEAST A MAJORITY (I.E., GREATER THAN FIFTY PERCENT)  OF
 THE REBATES.
   (I) FOR PURPOSES OF THIS SUBPARAGRAPH, "REBATE" MEANS:
   (1)  NEGOTIATED  PRICE  CONCESSIONS  INCLUDING BUT NOT LIMITED TO BASE
 REBATES AND REASONABLE ESTIMATES OF ANY  PRICE  PROTECTION  REBATES  AND
 PERFORMANCE-BASED  REBATES THAT MAY ACCRUE DIRECTLY OR INDIRECTLY TO THE
 ISSUER DURING THE COVERAGE YEAR FROM A MANUFACTURER, DISPENSING  PHARMA-
 CY, OR OTHER PARTY TO THE TRANSACTION; AND
   (2)  REASONABLE  ESTIMATES  OF ANY FEES AND OTHER ADMINISTRATIVE COSTS
 THAT ARE PASSED THROUGH TO THE ISSUER AND SERVE TO REDUCE  THE  ISSUER'S
 PRESCRIPTION DRUG LIABILITIES FOR THE COVERAGE YEAR.
   (II)  IN  PROVIDING  THE CERTIFICATION REQUIRED UNDER THIS SECTION, AN
 ISSUER SHALL NOT PUBLISH OR OTHERWISE REVEAL INFORMATION  REGARDING  THE
 ACTUAL  AMOUNT OF REBATES THE ISSUER RECEIVED ON A PRODUCT-, MANUFACTUR-
 ER-, OR PHARMACY-SPECIFIC BASIS.   SUCH INFORMATION IS  PROTECTED  AS  A
 TRADE  SECRET,  IS NOT A PUBLIC RECORD AS DEFINED IN THE PUBLIC OFFICERS
 LAW AND SHALL NOT BE DISCLOSED DIRECTLY OR INDIRECTLY. AN INSURER  SHALL
 IMPOSE  THE  CONFIDENTIALITY  PROTECTIONS  OF  THIS SECTION ON ANY THIRD
 PARTIES OR VENDORS WITH WHICH IT CONTRACTS  THAT  MAY  RECEIVE  OR  HAVE
 ACCESS TO REBATE INFORMATION.
   §  20.  Subsection (b) of section 3221 of the insurance law is amended
 to read as follows:
   (b) (1) No such policy shall be delivered or issued  for  delivery  in
 this  state  unless  a  schedule of the premium rates pertaining to such
 form shall have been filed with the superintendent.
   (2) AN INSURER SHALL ANNUALLY CERTIFY TO THE DEPARTMENT  THAT,  DURING
 THE  PRIOR  BENEFIT YEAR, THE INSURER MADE AVAILABLE TO ENROLLEES AT THE
 POINT OF SALE AT LEAST A MAJORITY (I.E., GREATER THAN FIFTY PERCENT)  OF
 THE REBATES.
   (A) FOR PURPOSES OF THIS PARAGRAPH, "REBATE" MEANS:
   (I)  NEGOTIATED  PRICE  CONCESSIONS  INCLUDING BUT NOT LIMITED TO BASE
 REBATES AND REASONABLE ESTIMATES OF ANY  PRICE  PROTECTION  REBATES  AND
 PERFORMANCE-BASED  REBATES THAT MAY ACCRUE DIRECTLY OR INDIRECTLY TO THE
 ISSUER DURING THE COVERAGE YEAR FROM A MANUFACTURER, DISPENSING  PHARMA-
 CY, OR OTHER PARTY TO THE TRANSACTION; AND
   (II)  REASONABLE  ESTIMATES OF ANY FEES AND OTHER ADMINISTRATIVE COSTS
 THAT ARE PASSED THROUGH TO THE ISSUER AND SERVE TO REDUCE  THE  ISSUER'S
 PRESCRIPTION DRUG LIABILITIES FOR THE COVERAGE YEAR.
   (B)  IN  PROVIDING  THE  CERTIFICATION REQUIRED UNDER THIS SECTION, AN
 ISSUER SHALL NOT PUBLISH OR OTHERWISE REVEAL INFORMATION  REGARDING  THE
 ACTUAL  AMOUNT OF REBATES THE ISSUER RECEIVED ON A PRODUCT-, MANUFACTUR-
 ER-, OR PHARMACY-SPECIFIC BASIS.   SUCH INFORMATION IS  PROTECTED  AS  A
 TRADE  SECRET,  IS NOT A PUBLIC RECORD AS DEFINED IN THE PUBLIC OFFICERS

 S. 6244                            13

 LAW AND SHALL NOT BE DISCLOSED DIRECTLY OR INDIRECTLY. AN INSURER  SHALL
 IMPOSE  THE  CONFIDENTIALITY  PROTECTIONS  OF  THIS SECTION ON ANY THIRD
 PARTIES OR VENDORS WITH WHICH IT CONTRACTS  THAT  MAY  RECEIVE  OR  HAVE
 ACCESS TO REBATE INFORMATION.
   §  21.  Severability.  If  any  item,  clause, sentence, subparagraph,
 subdivision or other part of this act, or the application thereof to any
 person or circumstances shall be held to be invalid, such holding  shall
 not  affect, impair or invalidate the remainder of this act but it shall
 be confined in its operation to the  item,  clause,  sentence,  subpara-
 graph,  subdivision  or other part of this act directly involved in such
 holding, or to the person and circumstances therein involved.
   § 22. This act shall take effect immediately and shall apply to insur-
 ance policies issued, amended, or renewed on or after January  1,  2020;
 provided, however, that the amendments to subdivision 9 of section 367-a
 of  the  social  services law made by section fourteen of this act shall
 not affect the expiration of such subdivision pursuant to section  4  of
 chapter  19 of the laws of 1998, as amended, and shall expire therewith;
 and provided, further, that the  amendments  to  section  364-j  of  the
 social services law made by section fifteen of this act shall not affect
 the  repeal  of  such  section  and  shall be deemed repealed therewith.
 Effective immediately the addition, amendment or repeal of any  rule  or
 regulation necessary for the implementation of this act on its effective
 date are authorized to be made and completed on or before such date.