NY State Senate Bill S4620C

Archive: Last Bill Status - Signed by Governor

Introduced
In Committee
On Floor Calendar
- Passed Senate
- Passed Assembly
Delivered to Governor
Signed by Governor

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Actions

view actions (20)

	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Dec 30, 2022	approval memo.104 signed chap.826
Dec 19, 2022	delivered to governor
May 31, 2022	returned to senate passed assembly ordered to third reading cal.594 substituted for a5411d
May 24, 2022	referred to insurance delivered to assembly passed senate
May 23, 2022	ordered to third reading cal.1427 committee discharged and committed to rules
May 17, 2022	print number 4620c
May 17, 2022	amend and recommit to insurance
May 02, 2022	print number 4620b
May 02, 2022	amend and recommit to insurance
Jan 05, 2022	referred to insurance
Apr 28, 2021	print number 4620a
Apr 28, 2021	amend and recommit to insurance
Feb 08, 2021	referred to insurance

Votes

Bill Amendments

Original

C (Active)

Original

C (Active)

S4620 - Details

See Assembly Version of this Bill:: A5411
Law Section:: Insurance Law
Laws Affected:: Add §341-a, Ins L

S4620 - Summary

Requires health plans operating in the state to furnish the cost, benefit, and coverage data as required to the enrollee, his or her health care provider, or the third-party of his or her choosing.

S4620 - Sponsor Memo

 
BILL NUMBER: S4620

SPONSOR: BRESLIN
 
TITLE OF BILL:

An act to amend the insurance law, in relation to enacting the "patient
Rx information and choice expansion act"

 
PURPOSE:

The bill requires that real-time, patient specific, prescription drug
out-of-pocket cost details be provided at the point of prescribing which
will enable all patients a better understanding of what the out-of-
pocketò costs will be for their medications and greater transparency
overall.

 
SUMMARY OF PROVISIONS:

Section 1 titles the bill, the patient Rx information and choice expan-
sion act or the "PRICE" act.

Section 2 provides the definitions for terms related to patient
prescription pricing transparency. The section also establishes an inte-
gration requirement for health plans to allow real time benefit informa-
tion to be available immediately. The information that is required to be
provided in the real time benefit tool is outlined which includes
prescription cost and benefit information, cost sharing, eligibility,
alternatives, and prior authorization.

Section 3 sets the effective date.

 
JUSTIFICATION:

This bill seeks to address affordability and transparency issues that
affect prescription drug use and adherence. The out-of-pocket cost
burden for medically necessary treatments for patients can negatively
impact the likelihood of beginning treatment and adherence, leading to
overall drug abandonment rates. In addition, the use of high deductible
plans is growing resulting in increased costs for patients for medically
necessary treatments.

Patient nonadherence to necessary prescribed medications is associated
with poor clinical outcomes, progression of disease, and an estimated
burden of billions per year in avoidable direct health care costs.
Between $100 and $300 billion of avoidable health care costs have been
attributed to nonadherence in the U.S. annually, representing 3 to 10%
of total US health care costs. The Centers for Medicare and Medicaid
Services (CMS) have found that health plans and entities acting on their
behalf may have misaligned incentives driving utilization of higher cost
medicines and hindering patient choice to lower cost options due to a
lack of price transparency. Per CMS, prescription price transparency is
critical to lowering overall drug costs and patient out-of-pocket costs
and supports improved medication adherence. At a time when patients are
being required to pay more and more out-of-pocket for healthcare, they
need access to real-time, patient-specific information via means of
their choosing.  To achieve cost savings, patients must understand their
drug benefit coverage and payment considerations for drugs on and off a
plan's formulary, including lower cost clinical and therapeutic alterna-
tives.  The real time benefit tool provides a proactive look at which
medications need prior approval. The tool will allow an alternative
prescription or will alert the provider that a prior approval is needed
and a process to expedite the steps to acquire a prior approval.

Due to the COVID-19 pandemic, healthcare professionals may not always be
available to assist patients as they navigate prescription cost process
and now, more than ever, patients need access to tools and resources at
all points in the prescription process that empowers them with them
up-to-date prescription pricing options.

 
LEGISLATIVE HISTORY:

New bill

 
EFFECTIVE DATE:
This act shall take effect July 1, 2023.

S4620 - Bill Text download pdf

 
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   4620
 
                        2021-2022 Regular Sessions
 
                             I N  S E N A T E
 
                             February 8, 2021
                                ___________
 
 Introduced  by  Sen. BRESLIN -- read twice and ordered printed, and when
   printed to be committed to the Committee on Insurance
 
 AN ACT to amend the insurance law, in relation to enacting the  "patient
   Rx information and choice expansion act"
 
   THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. This act shall be known and may be cited as the "patient Rx
 information and choice expansion act" or the "PRICE act".
   § 2. The insurance law is amended by adding a  new  section  341-a  to
 read as follows:
   §  341-A.  PATIENT PRESCRIPTION PRICING TRANSPARENCY. 1.  DEFINITIONS.
 AS USED IN THIS SECTION:
   (A) "HEALTH PLAN" MEANS BENEFITS PROVIDED BY ANY ENTITY DELIVERING  OR
 ISSUING  FOR DELIVERY A POLICY OF ACCIDENT AND HEALTH INSURANCE PURSUANT
 TO SECTION THREE THOUSAND TWO HUNDRED SIXTEEN, OR  A  GROUP  OR  BLANKET
 ACCIDENT  AND HEALTH INSURANCE POLICY PURSUANT TO SECTION THREE THOUSAND
 TWO HUNDRED TWENTY-ONE, OR PROVIDING BENEFITS PURSUANT TO  SECTION  FOUR
 THOUSAND THREE HUNDRED THREE OF THIS CHAPTER.
   (B)  "COST-SHARING  INFORMATION"  MEANS  THE  AMOUNT  AN  ENROLLEE  IS
 REQUIRED TO PAY IN ORDER TO RECEIVE A DRUG THAT  IS  COVERED  UNDER  THE
 ENROLLEE'S HEALTH PLAN.
   (C)  "COVERED/COVERAGE"  MEANS  THOSE HEALTH CARE SERVICES TO WHICH AN
 ENROLLEE IS ENTITLED UNDER THE TERMS OF THE HEALTH PLAN.
   (D) "ENROLLEE" MEANS THE COVERED INDIVIDUAL, POLICYHOLDER, SUBSCRIBER,
 THE INSURED, OR PERSON WHO HAS AUTHORITY UNDER APPLICABLE LAW TO ACT  ON
 BEHALF  OF  AN  ENROLLEE  IN  MAKING DECISIONS RELATED TO HEALTH CARE, A
 HEALTH PLAN, OR PHARMACY BENEFIT MANAGER, OR ITS AFFILIATES OR ENTITIES.
   (E) "INTEROPERABILITY ELEMENT" MEANS  HARDWARE,  SOFTWARE,  INTEGRATED
 TECHNOLOGIES  OR  RELATED  LICENSES,  TECHNICAL INFORMATION, PRIVILEGES,
 RIGHTS, INTELLECTUAL PROPERTY, UPGRADES, OR SERVICES THAT MAY BE  NECES-
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD08942-01-1

 S. 4620                             2
 
 SARY TO PROVIDE THE DATA REQUIRED IN THE REQUESTED FORMAT AND CONSISTENT
 WITH THE REQUIRED FORMAT.
   (F)  "PHARMACY  BENEFIT  MANAGER (PBM)" ENSURE THAT THIS TERM INCLUDES
 PHARMACY BENEFIT MANAGERS, AFFILIATES, OR OTHER ENTITIES ACTING ON THEIR
 BEHALF.
   (G) "ELECTRONIC HEALTH RECORD" MEANS A DIGITAL VERSION OF A  PATIENT'S
 PAPER  CHART  AND  MEDICAL  HISTORY  THAT  MAKES  INFORMATION  AVAILABLE
 INSTANTLY AND SECURELY TO AUTHORIZED USERS.
   (H) "ELECTRONIC PRESCRIBING SYSTEM" MEANS A SYSTEM THAT ENABLES  PRES-
 CRIBERS  TO  ENTER PRESCRIPTION INFORMATION INTO A COMPUTER PRESCRIPTION
 DEVICE AND SECURELY TRANSMIT THE  PRESCRIPTION  TO  PHARMACIES  USING  A
 SPECIAL SOFTWARE PROGRAM AND CONNECTIVITY TO A TRANSMISSION NETWORK.
   (I)  "ELECTRONIC  PRESCRIPTION"  MEANS  AN  ELECTRONIC PRESCRIPTION AS
 DEFINED IN SECTION THIRTY-THREE HUNDRED TWO OF THE PUBLIC HEALTH LAW.
   (J) "PRESCRIBER" MEANS A HEALTH CARE PROVIDER  LICENSED  TO  PRESCRIBE
 MEDICATION OR MEDICAL DEVICES IN THE STATE.
   (K)   "REAL-TIME   BENEFIT   TOOL"   OR  "RTBT"  MEANS  AN  ELECTRONIC
 PRESCRIPTION DECISION SUPPORT TOOL THAT: (I) IS CAPABLE  OF  INTEGRATING
 WITH  PRESCRIBERS'  ELECTRONIC  PRESCRIBING AND ELECTRONIC HEALTH RECORD
 SYSTEMS; AND (II) COMPLIES WITH THE TECHNICAL STANDARDS ADOPTED  BY  THE
 NATIONAL COUNCIL FOR PRESCRIPTION DRUG PROGRAMS (NCPDP).
   2.  NO  LATER  THAN JULY FIRST, TWO THOUSAND TWENTY-THREE, EACH HEALTH
 PLAN OPERATING IN THE STATE SHALL, UPON REQUEST OF THE ENROLLEE, HIS  OR
 HER  HEALTH CARE PROVIDER, OR A THIRD-PARTY ON THEIR BEHALF, FURNISH THE
 COST, BENEFIT, AND COVERAGE DATA SET FORTH AS REQUIRED TO THE  ENROLLEE,
 HIS OR HER HEALTH CARE PROVIDER, OR THE THIRD-PARTY OF HIS OR HER CHOOS-
 ING  AND  SHALL  ENSURE  THAT SUCH DATA IS (I) CURRENT NO LATER THAN ONE
 BUSINESS DAY AFTER ANY CHANGE IS MADE; (II) PROVIDED IN REAL  TIME;  AND
 (III) IN THE SAME FORMAT THAT THE REQUEST IS MADE BY THE ENROLLEE OR HIS
 OR HER HEALTH CARE PROVIDER.
   3.  THE  FORMAT  OF THE REQUEST SHALL USE ESTABLISHED INDUSTRY CONTENT
 AND TRANSPORT STANDARDS PUBLISHED BY:
   (A) A STANDARDS DEVELOPING ORGANIZATION  ACCREDITED  BY  THE  AMERICAN
 NATIONAL STANDARDS INSTITUTE (ANSI), INCLUDING, THE NATIONAL COUNCIL FOR
 PRESCRIPTION DRUG PROGRAMS (NCPDP), ASC X12, HEALTH LEVEL 7; OR
   (B)  A  RELEVANT FEDERAL OR STATE GOVERNING BODY, INCLUDING THE CENTER
 FOR MEDICARE & MEDICAID SERVICES OR THE OFFICE OF THE NATIONAL COORDINA-
 TOR FOR HEALTH INFORMATION TECHNOLOGY.
   4. A FACSIMILE, PROPRIETARY PAYOR OR PATIENT PORTAL,  OR  OTHER  ELEC-
 TRONIC FORM SHALL NOT BE CONSIDERED ACCEPTABLE ELECTRONIC FORMATS PURSU-
 ANT TO THIS SECTION.
   5.  UPON  SUCH  REQUEST,  THE FOLLOWING DATA SHALL BE PROVIDED FOR ANY
 DRUG COVERED UNDER THE ENROLLEE'S HEALTH PLAN:
   (A) PATIENT-SPECIFIC ELIGIBILITY INFORMATION;
   (B) PATIENT-SPECIFIC PRESCRIPTION  COST  AND  BENEFIT  DATA,  SUCH  AS
 APPLICABLE  FORMULARY,  BENEFIT,  COVERAGE AND COST-SHARING DATA FOR THE
 PRESCRIBED DRUG AND CLINICALLY-APPROPRIATE ALTERNATIVES, WHEN  APPROPRI-
 ATE;
   (C)  PATIENT-SPECIFIC COST-SHARING INFORMATION THAT DESCRIBES VARIANCE
 IN COST-SHARING BASED ON THE PHARMACY DISPENSING THE PRESCRIBED DRUG  OR
 ITS  ALTERNATIVES, AND IN RELATION TO THE PATIENT'S BENEFIT (I.E., SPEND
 RELATED TO OUT-OF-POCKET MAXIMUM);
   (D) INFORMATION REGARDING LOWER COST CLINICALLY-APPROPRIATE  TREATMENT
 ALTERNATIVES; AND

 S. 4620                             3
 
   (E)  APPLICABLE  UTILIZATION  MANAGEMENT  REQUIREMENTS,  SUCH AS PRIOR
 AUTHORIZATION,  STEP  THERAPY,  QUANTITY  LIMITS,  AND   SITE-OF-SERVICE
 RESTRICTIONS.
   6.  ANY  HEALTH PLAN OR PBM SHALL FURNISH THE DATA AS REQUIRED WHETHER
 THE REQUEST IS MADE USING THE DRUG'S UNIQUE  BILLING  CODE,  SUCH  AS  A
 NATIONAL  DRUG CODE OR HEALTHCARE COMMON PROCEDURE CODING SYSTEM CODE OR
 DESCRIPTIVE TERM, SUCH AS THE BRAND OR GENERIC NAME OF THE  DRUG.      A
 HEALTH  PLAN  OR  PBM  SHALL  NOT DENY OR DELAY A REQUEST AS A METHOD OF
 BLOCKING THE DATA SET FORTH AS REQUIRED FROM BEING SHARED BASED  ON  HOW
 THE DRUG WAS REQUESTED.
   7.  A HEALTH PLAN, OR ENTITIES ACTING ON A HEALTH PLAN'S BEHALF, SHALL
 NOT RESTRICT, PROHIBIT, OR OTHERWISE HINDER  THE PRESCRIBER FROM  COMMU-
 NICATING OR SHARING BENEFIT AND COVERAGE INFORMATION THAT REFLECTS OTHER
 CHOICES,  SUCH AS CASH PRICE, LOWER COST CLINICALLY-APPROPRIATE ALTERNA-
 TIVES, WHETHER OR NOT  THEY  ARE  COVERED  UNDER  THE  ENROLLEE'S  PLAN,
 PATIENT  ASSISTANCE  AND  SUPPORT PROGRAMS AND THE COST AVAILABLE AT THE
 PATIENT'S PHARMACY OF CHOICE.
   8. A HEALTH PLAN, OR ENTITIES ACTING ON A HEALTH PLAN'S BEHALF,  SHALL
 NOT, EXCEPT AS MAY BE REQUIRED BY LAW, INTERFERE WITH, PREVENT, OR MATE-
 RIALLY  DISCOURAGE  ACCESS,  EXCHANGE,  OR  USE OF THE DATA AS REQUIRED,
 WHICH MAY INCLUDE CHARGING FEES, NOT RESPONDING TO A REQUEST AT THE TIME
 MADE WHERE SUCH A RESPONSE IS REASONABLY POSSIBLE, IMPLEMENTING TECHNOL-
 OGY IN NONSTANDARD WAYS OR INSTITUTING  ENROLLEE  CONSENT  REQUIREMENTS,
 PROCESSES, POLICIES, PROCEDURES, OR RENEWALS THAT ARE LIKELY TO SUBSTAN-
 TIALLY  INCREASE  THE  COMPLEXITY OR BURDEN OF ACCESSING, EXCHANGING, OR
 USING SUCH DATA; NOR PENALIZE A HEALTH CARE PROVIDER OR PROFESSIONAL FOR
 DISCLOSING SUCH INFORMATION TO AN ENROLLEE OR  PRESCRIBING,  ADMINISTER-
 ING, OR ORDERING A CLINICALLY APPROPRIATE OR LOWER-COST ALTERNATIVE.
   9.  NOTHING  IN THIS SECTION SHALL BE CONSTRUED TO LIMIT ACCESS TO THE
 MOST  UP-TO-DATE  PATIENT-SPECIFIC   ELIGIBILITY   OR   PATIENT-SPECIFIC
 PRESCRIPTION COST AND BENEFIT DATA BY THE HEALTH PLAN.
   10.  NOTHING IN THIS SECTION SHALL INTERFERE WITH PATIENT CHOICE AND A
 HEALTH  CARE  PROFESSIONAL'S  ABILITY  TO  CONVEY  THE  FULL  RANGE   OF
 PRESCRIPTION  DRUG COST OPTIONS TO A PATIENT.  HEALTH PLANS, OR ENTITIES
 ACTING ON THEIR BEHALF, SHALL NOT RESTRICT A  HEALTH  CARE  PROFESSIONAL
 FROM COMMUNICATING TO THE PATIENT PRESCRIPTION COST OPTIONS.
   11.  NO  RTBT SHALL REQUIRE OR INFLUENCE A PATIENT TO UTILIZE SPECIFIC
 PLAN PREFERRED DRUGS OR PHARMACIES.
   § 3. This act shall take effect July 1, 2023.  Effective  immediately,
 the  addition,  amendment and/or repeal of any rule or regulation neces-
 sary for the implementation of  this  act  on  its  effective  date  are
 authorized to be made and completed on or before such effective date.

S4620A - Details

See Assembly Version of this Bill:: A5411
Law Section:: Insurance Law
Laws Affected:: Add §341-a, Ins L

S4620A - Summary

Requires health plans operating in the state to furnish the cost, benefit, and coverage data as required to the enrollee, his or her health care provider, or the third-party of his or her choosing.

S4620A - Sponsor Memo

 
BILL NUMBER: S4620A

SPONSOR: BRESLIN
 
TITLE OF BILL:

An act to amend the insurance law, in relation to enacting the "patient
Rx information and choice expansion act"

 
PURPOSE:

The bill requires that real-time, patient specific, prescription drug
out-of-pocket cost details be provided at the point of prescribing which
will enable all patients a better understanding of what the out-of-
pocketò costs will be for their medications and greater transparency
overall.

 
SUMMARY OF PROVISIONS:

Section 1 titles the bill, the patient Rx information and choice expan-
sion act or the "PRICE" act.

Section 2 provides the definitions for terms related to patient
prescription pricing transparency. The section also establishes an inte-
gration requirement for health plans to allow real time benefit informa-
tion to be available immediately. The information that is required to be
provided in the real time benefit tool is outlined which includes
prescription cost and benefit information, cost sharing, eligibility,
alternatives, and prior authorization.

Section 3 sets the effective date.

 
JUSTIFICATION:

This bill seeks to address affordability and transparency issues that
affect prescription drug use and adherence. The out-of-pocket cost
burden for medically necessary treatments for patients can negatively
impact the likelihood of beginning treatment and adherence, leading to
overall drug. abandonment rates. In addition, the use of high deductible
plans is growing resulting in increased costs for patients for medically
necessary treatments.

Patient nonadherence to necessary prescribed medications is associated
with poor clinical outcomes, progression of disease, and an estimated
burden of billions per year in avoidable direct health care costs.
Between $100 and $300 billion of avoidable health care costs have been
attributed to nonadherence in the U.S. annually, representing 3 to 10%
of total US health care costs. The Centers for Medicare and Medicaid
Services (CMS) have found that health plans and entities acting on their
behalf may have misaligned incentives driving utilization of higher cost
medicines and hindering patient choice to lower cost options due to a
lack of price transparency. Per CMS, prescription price transparency is
critical to lowering overall drug costs and patient out-of-pocket costs
and supports improved medication adherence. At a time when patients are
being required to pay more and more out-of-pocket for healthcare, they
need access to real-time, patient-specific information via means of
their choosing. To achieve cost savings, patients must understand their
drug benefit coverage and payment considerations for drugs on and off a
plan's formulary, including lower cost clinical and therapeutic alterna-
tives. The real time benefit tool provides a proactive look at which
medications need prior approval. The tool will allow an alternative
prescription or will alert the provider that a prior approval is needed
and a process to expedite the steps to acquire a prior approval.

Due to the COVID-l9 pandemic, healthcare professionals may not always be
available to assist patients as they navigate prescription cost process
and now, more than ever, patients need access to tools and resources at
all points in the prescription process that empowers them with them
up-to-date prescription pricing options.

 
LEGISLATIVE HISTORY:

New bill

 
EFFECTIVE DATE:
This act shall take effect July 1, 2023.

S4620A - Bill Text download pdf

 
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  4620--A
 
                        2021-2022 Regular Sessions
 
                             I N  S E N A T E
 
                             February 8, 2021
                                ___________
 
 Introduced  by  Sen. BRESLIN -- read twice and ordered printed, and when
   printed to be committed to the Committee  on  Insurance  --  committee
   discharged, bill amended, ordered reprinted as amended and recommitted
   to said committee
 
 AN  ACT to amend the insurance law, in relation to enacting the "patient
   Rx information and choice expansion act"

   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. This act shall be known and may be cited as the "patient Rx
 information and choice expansion act" or the "PRICE act".
   §  2.  The  insurance  law is amended by adding a new section 341-a to
 read as follows:
   § 341-A. PATIENT PRESCRIPTION PRICING TRANSPARENCY. 1.    DEFINITIONS.
 AS USED IN THIS SECTION:
   (A)  "HEALTH PLAN" MEANS BENEFITS PROVIDED BY ANY ENTITY DELIVERING OR
 ISSUING FOR DELIVERY A POLICY OF ACCIDENT AND HEALTH INSURANCE  PURSUANT
 TO  SECTION  THREE  THOUSAND  TWO HUNDRED SIXTEEN, OR A GROUP OR BLANKET
 ACCIDENT AND HEALTH INSURANCE POLICY PURSUANT TO SECTION THREE  THOUSAND
 TWO  HUNDRED  TWENTY-ONE, OR PROVIDING BENEFITS PURSUANT TO SECTION FOUR
 THOUSAND THREE HUNDRED THREE OF THIS CHAPTER.
   (B)  "COST-SHARING  INFORMATION"  MEANS  THE  AMOUNT  AN  ENROLLEE  IS
 REQUIRED  TO  PAY  IN  ORDER TO RECEIVE A DRUG THAT IS COVERED UNDER THE
 ENROLLEE'S HEALTH PLAN.
   (C) "COVERED/COVERAGE" MEANS THOSE HEALTH CARE SERVICES  TO  WHICH  AN
 ENROLLEE IS ENTITLED UNDER THE TERMS OF THE HEALTH PLAN.
   (D) "ENROLLEE" MEANS THE COVERED INDIVIDUAL, POLICYHOLDER, SUBSCRIBER,
 THE  INSURED, OR PERSON WHO HAS AUTHORITY UNDER APPLICABLE LAW TO ACT ON
 BEHALF OF AN ENROLLEE IN MAKING DECISIONS  RELATED  TO  HEALTH  CARE,  A
 HEALTH PLAN, OR PHARMACY BENEFIT MANAGER, OR ITS AFFILIATES OR ENTITIES.
   (E)  "INTEROPERABILITY  ELEMENT"  MEANS HARDWARE, SOFTWARE, INTEGRATED
 TECHNOLOGIES OR RELATED  LICENSES,  TECHNICAL  INFORMATION,  PRIVILEGES,
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.

                                                            LBD08942-03-1

 S. 4620--A                          2
 
 RIGHTS,  INTELLECTUAL PROPERTY, UPGRADES, OR SERVICES THAT MAY BE NECES-
 SARY TO PROVIDE THE DATA REQUIRED IN THE REQUESTED FORMAT AND CONSISTENT
 WITH THE REQUIRED FORMAT.
   (F)  "PHARMACY  BENEFIT  MANAGER (PBM)" ENSURE THAT THIS TERM INCLUDES
 PHARMACY BENEFIT MANAGERS, AFFILIATES, OR OTHER ENTITIES ACTING ON THEIR
 BEHALF.
   (G) "ELECTRONIC HEALTH RECORD" MEANS A DIGITAL VERSION OF A  PATIENT'S
 PAPER  CHART  AND  MEDICAL  HISTORY  THAT  MAKES  INFORMATION  AVAILABLE
 INSTANTLY AND SECURELY TO AUTHORIZED USERS.
   (H) "ELECTRONIC PRESCRIBING SYSTEM" MEANS A SYSTEM THAT ENABLES  PRES-
 CRIBERS  TO  ENTER PRESCRIPTION INFORMATION INTO A COMPUTER PRESCRIPTION
 DEVICE AND SECURELY TRANSMIT THE  PRESCRIPTION  TO  PHARMACIES  USING  A
 SPECIAL SOFTWARE PROGRAM AND CONNECTIVITY TO A TRANSMISSION NETWORK.
   (I)  "ELECTRONIC  PRESCRIPTION"  MEANS  AN  ELECTRONIC PRESCRIPTION AS
 DEFINED IN SECTION THIRTY-THREE HUNDRED TWO OF THE PUBLIC HEALTH LAW.
   (J) "PRESCRIBER" MEANS A HEALTH CARE PROVIDER  LICENSED  TO  PRESCRIBE
 MEDICATION OR MEDICAL DEVICES IN THE STATE.
   (K)   "REAL-TIME   BENEFIT   TOOL"   OR  "RTBT"  MEANS  AN  ELECTRONIC
 PRESCRIPTION DECISION SUPPORT TOOL THAT: (I) IS CAPABLE  OF  INTEGRATING
 WITH  PRESCRIBERS'  ELECTRONIC  PRESCRIBING AND ELECTRONIC HEALTH RECORD
 SYSTEMS; AND (II) COMPLIES WITH THE TECHNICAL STANDARDS ADOPTED  BY  THE
 NATIONAL COUNCIL FOR PRESCRIPTION DRUG PROGRAMS (NCPDP).
   2.  NO  LATER  THAN JULY FIRST, TWO THOUSAND TWENTY-THREE, EACH HEALTH
 PLAN OPERATING IN THE STATE SHALL, UPON REQUEST OF THE ENROLLEE, HIS  OR
 HER  HEALTH CARE PROVIDER, OR A THIRD-PARTY ON THEIR BEHALF, FURNISH THE
 COST, BENEFIT, AND COVERAGE DATA SET FORTH AS REQUIRED TO THE  ENROLLEE,
 HIS OR HER HEALTH CARE PROVIDER, OR THE THIRD-PARTY OF HIS OR HER CHOOS-
 ING  AND  SHALL  ENSURE  THAT SUCH DATA IS (I) CURRENT NO LATER THAN ONE
 BUSINESS DAY AFTER ANY CHANGE IS MADE; (II) PROVIDED IN REAL  TIME;  AND
 (III) IN THE SAME FORMAT THAT THE REQUEST IS MADE BY THE ENROLLEE OR HIS
 OR HER HEALTH CARE PROVIDER.
   3.  THE  FORMAT  OF THE REQUEST SHALL USE ESTABLISHED INDUSTRY CONTENT
 AND TRANSPORT STANDARDS PUBLISHED BY:
   (A) A STANDARDS DEVELOPING ORGANIZATION  ACCREDITED  BY  THE  AMERICAN
 NATIONAL STANDARDS INSTITUTE (ANSI), INCLUDING, THE NATIONAL COUNCIL FOR
 PRESCRIPTION DRUG PROGRAMS (NCPDP), ASC X12, HEALTH LEVEL 7; OR
   (B)  A  RELEVANT FEDERAL OR STATE GOVERNING BODY, INCLUDING THE CENTER
 FOR MEDICARE & MEDICAID SERVICES OR THE OFFICE OF THE NATIONAL COORDINA-
 TOR FOR HEALTH INFORMATION TECHNOLOGY.
   4. A FACSIMILE, PROPRIETARY PAYOR OR PATIENT PORTAL,  OR  OTHER  ELEC-
 TRONIC FORM SHALL NOT BE CONSIDERED ACCEPTABLE ELECTRONIC FORMATS PURSU-
 ANT TO THIS SECTION.
   5.  UPON  SUCH  REQUEST,  THE FOLLOWING DATA SHALL BE PROVIDED FOR ANY
 DRUG COVERED UNDER THE ENROLLEE'S HEALTH PLAN:
   (A) PATIENT-SPECIFIC ELIGIBILITY INFORMATION;
   (B) PATIENT-SPECIFIC PRESCRIPTION  COST  AND  BENEFIT  DATA,  SUCH  AS
 APPLICABLE  FORMULARY,  BENEFIT,  COVERAGE AND COST-SHARING DATA FOR THE
 PRESCRIBED DRUG AND CLINICALLY-APPROPRIATE ALTERNATIVES, WHEN  APPROPRI-
 ATE;
   (C)  PATIENT-SPECIFIC COST-SHARING INFORMATION THAT DESCRIBES VARIANCE
 IN COST-SHARING BASED ON THE PHARMACY DISPENSING THE PRESCRIBED DRUG  OR
 ITS  ALTERNATIVES, AND IN RELATION TO THE PATIENT'S BENEFIT (I.E., SPEND
 RELATED TO OUT-OF-POCKET MAXIMUM);
   (D) INFORMATION REGARDING LOWER COST CLINICALLY-APPROPRIATE  TREATMENT
 ALTERNATIVES; AND

 S. 4620--A                          3
 
   (E)  APPLICABLE  UTILIZATION  MANAGEMENT  REQUIREMENTS,  SUCH AS PRIOR
 AUTHORIZATION,  STEP  THERAPY,  QUANTITY  LIMITS,  AND   SITE-OF-SERVICE
 RESTRICTIONS.
   6.  ANY  HEALTH PLAN OR PBM SHALL FURNISH THE DATA AS REQUIRED WHETHER
 THE REQUEST IS MADE USING THE DRUG'S UNIQUE  BILLING  CODE,  SUCH  AS  A
 NATIONAL  DRUG CODE OR HEALTHCARE COMMON PROCEDURE CODING SYSTEM CODE OR
 DESCRIPTIVE TERM, SUCH AS THE BRAND OR GENERIC NAME OF THE  DRUG.      A
 HEALTH  PLAN  OR  PBM  SHALL  NOT DENY OR DELAY A REQUEST AS A METHOD OF
 BLOCKING THE DATA SET FORTH AS REQUIRED FROM BEING SHARED BASED  ON  HOW
 THE DRUG WAS REQUESTED.
   7.  A HEALTH PLAN, OR ENTITIES ACTING ON A HEALTH PLAN'S BEHALF, SHALL
 NOT RESTRICT, PROHIBIT, OR OTHERWISE HINDER  THE PRESCRIBER FROM  COMMU-
 NICATING OR SHARING BENEFIT AND COVERAGE INFORMATION THAT REFLECTS OTHER
 CHOICES,  SUCH AS CASH PRICE, LOWER COST CLINICALLY-APPROPRIATE ALTERNA-
 TIVES, WHETHER OR NOT  THEY  ARE  COVERED  UNDER  THE  ENROLLEE'S  PLAN,
 PATIENT  ASSISTANCE  AND  SUPPORT PROGRAMS AND THE COST AVAILABLE AT THE
 PATIENT'S PHARMACY OF CHOICE.
   8. A HEALTH PLAN, OR ENTITIES ACTING ON A HEALTH PLAN'S BEHALF,  SHALL
 NOT, EXCEPT AS MAY BE REQUIRED BY LAW, INTERFERE WITH, PREVENT, OR MATE-
 RIALLY  DISCOURAGE  ACCESS,  EXCHANGE,  OR  USE OF THE DATA AS REQUIRED,
 WHICH MAY INCLUDE CHARGING FEES, NOT RESPONDING TO A REQUEST AT THE TIME
 MADE WHERE SUCH A RESPONSE IS REASONABLY POSSIBLE, IMPLEMENTING TECHNOL-
 OGY IN NONSTANDARD WAYS OR INSTITUTING  ENROLLEE  CONSENT  REQUIREMENTS,
 PROCESSES, POLICIES, PROCEDURES, OR RENEWALS THAT ARE LIKELY TO SUBSTAN-
 TIALLY  INCREASE  THE  COMPLEXITY OR BURDEN OF ACCESSING, EXCHANGING, OR
 USING SUCH DATA; NOR PENALIZE A HEALTH CARE PROVIDER OR PROFESSIONAL FOR
 DISCLOSING SUCH INFORMATION TO AN ENROLLEE OR  PRESCRIBING,  ADMINISTER-
 ING, OR ORDERING A CLINICALLY APPROPRIATE OR LOWER-COST ALTERNATIVE.
   9.  NOTHING  IN THIS SECTION SHALL BE CONSTRUED TO LIMIT ACCESS TO THE
 MOST  UP-TO-DATE  PATIENT-SPECIFIC   ELIGIBILITY   OR   PATIENT-SPECIFIC
 PRESCRIPTION COST AND BENEFIT DATA BY THE HEALTH PLAN.
   10.  NOTHING IN THIS SECTION SHALL INTERFERE WITH PATIENT CHOICE AND A
 HEALTH  CARE  PROFESSIONAL'S  ABILITY  TO  CONVEY  THE  FULL  RANGE   OF
 PRESCRIPTION  DRUG COST OPTIONS TO A PATIENT.  HEALTH PLANS, OR ENTITIES
 ACTING ON THEIR BEHALF, SHALL NOT RESTRICT A  HEALTH  CARE  PROFESSIONAL
 FROM COMMUNICATING TO THE PATIENT PRESCRIPTION COST OPTIONS.
   11.  NO  RTBT SHALL REQUIRE OR INFLUENCE A PATIENT TO UTILIZE SPECIFIC
 PLAN PREFERRED DRUGS OR PHARMACIES.
   § 3.  Severability. If any provision of this act, or  any  application
 of  any  provision of this  act, is held to be invalid, or to violate or
 be inconsistent with any   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,  which
 can  be given effect  without that provision or application; and to that
 end, the provisions  and applications of this act are severable.
   § 4. This act shall take effect July 1, 2023.  Effective  immediately,
 the  addition,  amendment and/or repeal of any rule or regulation neces-
 sary for the implementation of  this  act  on  its  effective  date  are
 authorized to be made and completed on or before such effective date.

S4620B - Details

See Assembly Version of this Bill:: A5411
Law Section:: Insurance Law
Laws Affected:: Add §341-a, Ins L

S4620B - Summary

Requires health plans operating in the state to furnish the cost, benefit, and coverage data as required to the enrollee, his or her health care provider, or the third-party of his or her choosing.

S4620B - Sponsor Memo

 
BILL NUMBER: S4620B

SPONSOR: BRESLIN
 
TITLE OF BILL:

An act to amend the insurance law, in relation to enacting the "patient
Rx information and choice expansion act"

 
PURPOSE:

The bill requires that real-time, patient specific, prescription drug
out-of-pocket cost details be provided at the point of prescribing which
will enable all patients a better understanding of what the out-of-
pocketò costs will be for their medications and greater transparency
overall.

 
SUMMARY OF PROVISIONS:

Section 1 titles the bill, the patient Rx information and choice expan-
sion act or the "PRICE" act.

Section 2 provides the definitions for terms related to patient

prescription pricing transparency. The section also establishes an inte-
gration requirement for health plans to allow real time benefit informa-
tion to be available immediately. The information that is required to be
provided in the real time benefit tool is outlined which includes
prescription cost and benefit information, cost sharing, eligibility,
alternatives, and prior authorization.

Section 3 sets the effective date.

 
JUSTIFICATION:

This bill seeks to address affordability and transparency issues that
affect prescription drug use and adherence. The out-of-pocket cost
burden for medically necessary treatments for patients can negatively
impact the likelihood of beginning treatment and adherence, leading to
overall drug. abandonment rates. In addition, the use of high deductible
plans is growing resulting in increased costs for patients for medically
necessary treatments.

Patient nonadherence to necessary prescribed medications is associated
with poor clinical outcomes, progression of disease, and an estimated
burden of billions per year in avoidable direct health care costs.
Between $100 and $300 billion of avoidable health care costs have been
attributed to nonadherence in the U.S. annually, representing 3 to 10%
of total US health care costs. The Centers for Medicare and Medicaid
Services (CMS) have found that health plans and entities acting on their
behalf may have misaligned incentives driving utilization of higher cost
medicines and hindering patient choice to lower cost options due to a
lack of price transparency. Per CMS, prescription price transparency is
critical to lowering overall drug costs and patient out-of-pocket costs
and supports improved medication adherence. At a time when patients are
being required to pay more and more out-of-pocket for healthcare, they
need access to real-time, patient-specific information via means of
their choosing. To achieve cost savings, patients must understand their
drug benefit coverage and payment considerations for drugs on and off a
plan's formulary, including lower cost clinical and therapeutic alterna-
tives. The real time benefit tool provides a proactive look at which
medications need prior approval. The tool will allow an alternative
prescription or will alert the provider that a prior approval is needed
and a process to expedite the steps to acquire a prior approval.

Due to the COVID-19 pandemic, healthcare professionals may not always be
available to assist patients as they navigate prescription cost process
and now, more than ever, patients need access to tools and resources at
all points in the prescription process that empowers them with them
up-to-date prescription pricing options.

 
LEGISLATIVE HISTORY:

New bill

 
EFFECTIVE DATE:
This act shall take effect July 1, 2023.

S4620B - Bill Text download pdf

 
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  4620--B
 
                        2021-2022 Regular Sessions
 
                             I N  S E N A T E
 
                             February 8, 2021
                                ___________
 
 Introduced  by  Sen. BRESLIN -- read twice and ordered printed, and when
   printed to be committed to the Committee  on  Insurance  --  committee
   discharged, bill amended, ordered reprinted as amended and recommitted
   to  said  committee  --  recommitted  to the Committee on Insurance in
   accordance with Senate Rule 6, sec. 8 --  committee  discharged,  bill
   amended,  ordered reprinted as amended and recommitted to said commit-
   tee
 
 AN ACT to amend the insurance law, in relation to enacting the  "patient
   Rx information and choice expansion act"
 
   THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. This act shall be known and may be cited as the "patient Rx
 information and choice expansion act" or the "PRICE act".
   § 2. The insurance law is amended by adding a  new  section  341-a  to
 read as follows:
   §  341-A.  PATIENT PRESCRIPTION PRICING TRANSPARENCY. 1.  DEFINITIONS.
 AS USED IN THIS SECTION:
   (A) "HEALTH PLAN" MEANS BENEFITS PROVIDED BY ANY ENTITY DELIVERING  OR
 ISSUING  FOR DELIVERY A POLICY OF ACCIDENT AND HEALTH INSURANCE PURSUANT
 TO SECTION THREE THOUSAND TWO HUNDRED SIXTEEN, OR  A  GROUP  OR  BLANKET
 ACCIDENT  AND HEALTH INSURANCE POLICY PURSUANT TO SECTION THREE THOUSAND
 TWO HUNDRED TWENTY-ONE, OR PROVIDING BENEFITS PURSUANT TO  SECTION  FOUR
 THOUSAND THREE HUNDRED THREE OF THIS CHAPTER.
   (B)  "COST-SHARING  INFORMATION"  MEANS  THE  AMOUNT  AN  ENROLLEE  IS
 REQUIRED TO PAY IN ORDER TO RECEIVE A DRUG THAT  IS  COVERED  UNDER  THE
 ENROLLEE'S HEALTH PLAN.
   (C)  "COVERED/COVERAGE"  MEANS  THOSE HEALTH CARE SERVICES TO WHICH AN
 ENROLLEE IS ENTITLED UNDER THE TERMS OF THE HEALTH PLAN.
   (D) "ENROLLEE" MEANS THE COVERED INDIVIDUAL, POLICYHOLDER, SUBSCRIBER,
 THE INSURED, OR PERSON WHO HAS AUTHORITY UNDER APPLICABLE LAW TO ACT  ON

  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD08942-07-2
 S. 4620--B                          2

 
 BEHALF  OF  AN  ENROLLEE  IN  MAKING DECISIONS RELATED TO HEALTH CARE, A
 HEALTH PLAN, OR PHARMACY BENEFIT MANAGER, OR ITS AFFILIATES OR ENTITIES.
   (E)  "INTEROPERABILITY  ELEMENT"  MEANS HARDWARE, SOFTWARE, INTEGRATED
 TECHNOLOGIES OR RELATED  LICENSES,  TECHNICAL  INFORMATION,  PRIVILEGES,
 RIGHTS,  INTELLECTUAL PROPERTY, UPGRADES, OR SERVICES THAT MAY BE NECES-
 SARY TO PROVIDE THE DATA REQUIRED IN THE REQUESTED FORMAT AND CONSISTENT
 WITH THE REQUIRED FORMAT.
   (F) "PHARMACY BENEFIT MANAGER (PBM)" ENSURE THAT  THIS  TERM  INCLUDES
 PHARMACY BENEFIT MANAGERS, AFFILIATES, OR OTHER ENTITIES ACTING ON THEIR
 BEHALF.
   (G)  "ELECTRONIC HEALTH RECORD" MEANS A DIGITAL VERSION OF A PATIENT'S
 PAPER  CHART  AND  MEDICAL  HISTORY  THAT  MAKES  INFORMATION  AVAILABLE
 INSTANTLY AND SECURELY TO AUTHORIZED USERS.
   (H)  "ELECTRONIC PRESCRIBING SYSTEM" MEANS A SYSTEM THAT ENABLES PRES-
 CRIBERS TO ENTER PRESCRIPTION INFORMATION INTO A  COMPUTER  PRESCRIPTION
 DEVICE  AND  SECURELY  TRANSMIT  THE  PRESCRIPTION TO PHARMACIES USING A
 SPECIAL SOFTWARE PROGRAM AND CONNECTIVITY TO A TRANSMISSION NETWORK.
   (I) "ELECTRONIC PRESCRIPTION"  MEANS  AN  ELECTRONIC  PRESCRIPTION  AS
 DEFINED IN SECTION THIRTY-THREE HUNDRED TWO OF THE PUBLIC HEALTH LAW.
   (J)  "PRESCRIBER"  MEANS  A HEALTH CARE PROVIDER LICENSED TO PRESCRIBE
 MEDICATION OR MEDICAL DEVICES IN THE STATE.
   (K)  "REAL-TIME  BENEFIT  TOOL"  OR   "RTBT"   MEANS   AN   ELECTRONIC
 PRESCRIPTION  DECISION  SUPPORT TOOL THAT: (I) IS CAPABLE OF INTEGRATING
 WITH PRESCRIBERS' ELECTRONIC PRESCRIBING AND  ELECTRONIC  HEALTH  RECORD
 SYSTEMS;  AND  (II)  COMPLIES WITH THE TECHNICAL STANDARDS ADOPTED BY AN
 AMERICAN NATIONAL STANDARDS INSTITUTE (ANSI) ACCREDITED STANDARDS DEVEL-
 OPMENT ORGANIZATION.
   2. NO LATER THAN JULY FIRST, TWO THOUSAND  TWENTY-THREE,  EACH  HEALTH
 PLAN  OPERATING IN THE STATE SHALL, UPON REQUEST OF THE ENROLLEE, HIS OR
 HER HEALTH CARE PROVIDER, OR A THIRD-PARTY ON THEIR BEHALF, FURNISH  THE
 COST,  BENEFIT, AND COVERAGE DATA SET FORTH AS REQUIRED TO THE ENROLLEE,
 HIS OR HER HEALTH CARE PROVIDER, OR THE THIRD-PARTY OF HIS OR HER CHOOS-
 ING AND SHALL ENSURE THAT SUCH DATA IS (I) CURRENT  NO  LATER  THAN  ONE
 BUSINESS  DAY  AFTER ANY CHANGE IS MADE; (II) PROVIDED IN REAL TIME; AND
 (III) IN THE SAME FORMAT THAT THE REQUEST IS MADE BY THE ENROLLEE OR HIS
 OR HER HEALTH CARE PROVIDER.
   3. THE FORMAT OF THE REQUEST SHALL USE  ESTABLISHED  INDUSTRY  CONTENT
 AND TRANSPORT STANDARDS PUBLISHED BY:
   (A)  A  STANDARDS  DEVELOPING  ORGANIZATION ACCREDITED BY THE AMERICAN
 NATIONAL STANDARDS INSTITUTE (ANSI), INCLUDING, THE NATIONAL COUNCIL FOR
 PRESCRIPTION DRUG PROGRAMS (NCPDP), ASC X12, HEALTH LEVEL 7; OR
   (B) A RELEVANT FEDERAL OR STATE GOVERNING BODY, INCLUDING  THE  CENTER
 FOR MEDICARE & MEDICAID SERVICES OR THE OFFICE OF THE NATIONAL COORDINA-
 TOR FOR HEALTH INFORMATION TECHNOLOGY.
   4.  A  FACSIMILE,  PROPRIETARY PAYOR OR PATIENT PORTAL, OR OTHER ELEC-
 TRONIC FORM SHALL NOT BE CONSIDERED ACCEPTABLE ELECTRONIC FORMATS PURSU-
 ANT TO THIS SECTION.
   5. UPON SUCH REQUEST, THE FOLLOWING DATA SHALL  BE  PROVIDED  FOR  ANY
 DRUG COVERED UNDER THE ENROLLEE'S HEALTH PLAN:
   (A) PATIENT-SPECIFIC ELIGIBILITY INFORMATION;
   (B)  PATIENT-SPECIFIC  PRESCRIPTION  COST  AND  BENEFIT  DATA, SUCH AS
 APPLICABLE FORMULARY, BENEFIT, COVERAGE AND COST-SHARING  DATA  FOR  THE
 PRESCRIBED  DRUG AND CLINICALLY-APPROPRIATE ALTERNATIVES, WHEN APPROPRI-
 ATE;
   (C) PATIENT-SPECIFIC COST-SHARING INFORMATION THAT DESCRIBES  VARIANCE
 IN  COST-SHARING BASED ON THE PHARMACY DISPENSING THE PRESCRIBED DRUG OR
 S. 4620--B                          3
 
 ITS ALTERNATIVES, AND IN RELATION TO THE PATIENT'S BENEFIT (I.E.,  SPEND
 RELATED TO OUT-OF-POCKET MAXIMUM);
   (D)  INFORMATION REGARDING LOWER COST CLINICALLY-APPROPRIATE TREATMENT
 ALTERNATIVES; AND
   (E) APPLICABLE UTILIZATION MANAGEMENT REQUIREMENTS.
   6. ANY HEALTH PLAN OR PBM SHALL FURNISH THE DATA AS  REQUIRED  WHETHER
 THE  REQUEST  IS  MADE  USING  THE DRUG'S UNIQUE BILLING CODE, SUCH AS A
 NATIONAL DRUG CODE OR HEALTHCARE COMMON PROCEDURE CODING SYSTEM CODE  OR
 DESCRIPTIVE TERM. A HEALTH PLAN OR PBM SHALL NOT DENY OR DELAY A REQUEST
 AS A METHOD OF BLOCKING THE DATA SET FORTH AS REQUIRED FROM BEING SHARED
 BASED ON HOW THE DRUG WAS REQUESTED.
   7.  A HEALTH PLAN, OR ENTITIES ACTING ON A HEALTH PLAN'S BEHALF, SHALL
 NOT RESTRICT, PROHIBIT, OR OTHERWISE HINDER  THE PRESCRIBER FROM  COMMU-
 NICATING OR SHARING BENEFIT AND COVERAGE INFORMATION THAT REFLECTS OTHER
 CHOICES,  SUCH AS CASH PRICE, LOWER COST CLINICALLY-APPROPRIATE ALTERNA-
 TIVES, WHETHER OR NOT  THEY  ARE  COVERED  UNDER  THE  ENROLLEE'S  PLAN,
 PATIENT  ASSISTANCE  AND  SUPPORT PROGRAMS AND THE COST AVAILABLE AT THE
 PATIENT'S PHARMACY OF CHOICE.
   8. A HEALTH PLAN, OR ENTITIES ACTING ON A HEALTH PLAN'S BEHALF,  SHALL
 NOT, EXCEPT AS MAY BE REQUIRED BY LAW, INTERFERE WITH, PREVENT, OR MATE-
 RIALLY  DISCOURAGE  ACCESS,  EXCHANGE,  OR  USE OF THE DATA AS REQUIRED,
 WHICH MAY INCLUDE CHARGING FEES, NOT RESPONDING TO A REQUEST AT THE TIME
 MADE WHERE SUCH A RESPONSE IS REASONABLY POSSIBLE, IMPLEMENTING TECHNOL-
 OGY IN NONSTANDARD WAYS OR INSTITUTING  ENROLLEE  CONSENT  REQUIREMENTS,
 PROCESSES, POLICIES, PROCEDURES, OR RENEWALS THAT ARE LIKELY TO SUBSTAN-
 TIALLY  INCREASE  THE  COMPLEXITY OR BURDEN OF ACCESSING, EXCHANGING, OR
 USING SUCH DATA; NOR PENALIZE A HEALTH CARE PROVIDER OR PROFESSIONAL FOR
 DISCLOSING SUCH INFORMATION TO AN ENROLLEE OR  PRESCRIBING,  ADMINISTER-
 ING, OR ORDERING A CLINICALLY APPROPRIATE OR LOWER-COST ALTERNATIVE.
   9.  NOTHING  IN THIS SECTION SHALL BE CONSTRUED TO LIMIT ACCESS TO THE
 MOST  UP-TO-DATE  PATIENT-SPECIFIC   ELIGIBILITY   OR   PATIENT-SPECIFIC
 PRESCRIPTION COST AND BENEFIT DATA BY THE HEALTH PLAN.
   10.  NOTHING IN THIS SECTION SHALL INTERFERE WITH PATIENT CHOICE AND A
 HEALTH  CARE  PROFESSIONAL'S  ABILITY  TO  CONVEY  THE  FULL  RANGE   OF
 PRESCRIPTION  DRUG COST OPTIONS TO A PATIENT.  HEALTH PLANS, OR ENTITIES
 ACTING ON THEIR BEHALF, SHALL NOT RESTRICT A  HEALTH  CARE  PROFESSIONAL
 FROM COMMUNICATING TO THE PATIENT PRESCRIPTION COST OPTIONS.
   11.  NO  RTBT SHALL REQUIRE OR INFLUENCE A PATIENT TO UTILIZE SPECIFIC
 PLAN PREFERRED DRUGS OR PHARMACIES.
   § 3.  Severability. If any provision of this act, or  any  application
 of  any  provision of this  act, is held to be invalid, or to violate or
 be inconsistent with any   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,  which
 can  be given effect  without that provision or application; and to that
 end, the provisions  and applications of this act are severable.
   § 4. This act shall take effect July 1, 2023.  Effective  immediately,
 the  addition,  amendment and/or repeal of any rule or regulation neces-
 sary for the implementation of  this  act  on  its  effective  date  are
 authorized to be made and completed on or before such effective date.

S4620C (ACTIVE) - Details

See Assembly Version of this Bill:: A5411
Law Section:: Insurance Law
Laws Affected:: Add §341-a, Ins L

S4620C (ACTIVE) - Summary

Requires health plans operating in the state to furnish the cost, benefit, and coverage data as required to the enrollee, his or her health care provider, or the third-party of his or her choosing.

S4620C (ACTIVE) - Sponsor Memo

 
BILL NUMBER: S4620C

SPONSOR: BRESLIN
 
TITLE OF BILL:

An act to amend the insurance law, in relation to enacting the "patient
Rx information and choice expansion act"

 
PURPOSE:

The bill requires that real-time, patient specific, prescription drug
out-of-pocket cost details be provided at the point of prescribing which
will enable all patients a better understanding of what the out-of-
pocketò costs will be for their medications and greater transparency
overall.

 
SUMMARY OF PROVISIONS:

Section 1 titles the bill, the patient Rx information and choice expan-
sion act or the "PRICE" act.

Section 2 provides the definitions for terms related to patient

prescription pricing transparency. The section also establishes an inte-
gration requirement for health plans to allow real time benefit informa-
tion to be available immediately. The information that is required to be
provided in the real time benefit tool is outlined which includes
prescription cost and benefit information, cost sharing, eligibility,
alternatives, and prior authorization.

Section 3 sets the effective date.

 
JUSTIFICATION:

This bill seeks to address affordability and transparency issues that
affect prescription drug use and adherence. The out-of-pocket cost
burden for medically necessary treatments for patients can negatively
impact the likelihood of beginning treatment and adherence, leading to
overall drug. abandonment rates. In addition, the use of high deductible
plans is growing resulting in increased costs for patients for medically
necessary treatments.

Patient nonadherence to necessary prescribed medications is associated
with poor clinical outcomes, progression of disease, and an estimated
burden of billions per year in avoidable direct health care costs.
Between $100 and $300 billion of avoidable health care costs have been
attributed to nonadherence in the U.S. annually, representing 3 to 10%
of total US health care costs. The Centers for Medicare and Medicaid
Services (CMS) have found that health plans and entities acting on their
behalf may have misaligned incentives driving utilization of higher cost
medicines and hindering patient choice to lower cost options due to a
lack of price transparency. Per CMS, prescription price transparency is
critical to lowering overall drug costs and patient out-of-pocket costs
and supports improved medication adherance. At a time when patients are
being required to pay more and more out-of-pocket for healthcare, they
need access to real-time, patient-specific information via means of
their choosing. To achieve cost savings, patients must understand their
drug benefit coverage and payment considerations for drugs on and off a
plan's formulary, including lower cost clinical and therapeutic alterna-
tives.  The real time benefit tool provides a proactive look at which
medications need prior approval. The tool will allow an alternative
prescription or will alert the provider that a prior approval is needed
and a process to expedite the steps to acquire a prior approval.

Due to the COVID-19 pandemic, healthcare professionals may not always be
available to assist patients as they navigate prescription cost process
and now, more than ever, patients need access to tools and resources at
all points in the prescription process that empowers them with them
up-to-date prescription pricing options.

 
LEGISLATIVE HISTORY:

New bill

 
EFFECTIVE DATE:
This act shall take effect July 1, 2023

S4620C (ACTIVE) - Bill Text download pdf

 
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  4620--C
 
                        2021-2022 Regular Sessions
 
                             I N  S E N A T E
 
                             February 8, 2021
                                ___________
 
 Introduced  by  Sen. BRESLIN -- read twice and ordered printed, and when
   printed to be committed to the Committee  on  Insurance  --  committee
   discharged, bill amended, ordered reprinted as amended and recommitted
   to  said  committee  --  recommitted  to the Committee on Insurance in
   accordance with Senate Rule 6, sec. 8 --  committee  discharged,  bill
   amended,  ordered reprinted as amended and recommitted to said commit-
   tee --  committee  discharged,  bill  amended,  ordered  reprinted  as
   amended and recommitted to said committee
 
 AN  ACT to amend the insurance law, in relation to enacting the "patient
   Rx information and choice expansion act"
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. This act shall be known and may be cited as the "patient Rx
 information and choice expansion act" or the "PRICE act".
   §  2.  The  insurance  law is amended by adding a new section 341-a to
 read as follows:
   § 341-A. PATIENT PRESCRIPTION PRICING TRANSPARENCY. 1.    DEFINITIONS.
 AS USED IN THIS SECTION:
   (A) THE TERMS "COVERED INDIVIDUAL", "HEALTH PLAN", AND "PHARMACY BENE-
 FIT  MANAGER"  SHALL  HAVE  THE  SAME MEANINGS AS DEFINED BY SECTION TWO
 HUNDRED EIGHTY-A  OF  THE  PUBLIC  HEALTH  LAW.  THE  SUPERINTENDENT  IS
 EXPRESSLY AUTHORIZED TO INTERPRET THESE TERMS AS IF THE DEFINITIONS WERE
 STATED WITHIN THIS ARTICLE.
   (B)  "COST-SHARING  INFORMATION" MEANS THE AMOUNT A COVERED INDIVIDUAL
 IS REQUIRED TO PAY TO RECEIVE A DRUG THAT IS COVERED UNDER  THE  COVERED
 INDIVIDUAL'S HEALTH PLAN.
   (C)  "COVERED/COVERAGE"  MEANS  THOSE  HEALTH CARE SERVICES TO WHICH A
 COVERED INDIVIDUAL IS ENTITLED UNDER THE TERMS OF THE HEALTH PLAN.
   (D) "INTEROPERABILITY ELEMENT" MEANS  HARDWARE,  SOFTWARE,  INTEGRATED
 TECHNOLOGIES  OR  RELATED  LICENSES,  TECHNICAL INFORMATION, PRIVILEGES,
 RIGHTS, INTELLECTUAL PROPERTY, UPGRADES, OR SERVICES THAT MAY BE  NECES-
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD08942-12-2

 S. 4620--C                          2
 
 SARY TO PROVIDE THE DATA REQUIRED IN THE REQUESTED FORMAT AND CONSISTENT
 WITH THE REQUIRED FORMAT.
   (E)  "ELECTRONIC HEALTH RECORD" MEANS A DIGITAL VERSION OF A PATIENT'S
 PAPER  CHART  AND  MEDICAL  HISTORY  THAT  MAKES  INFORMATION  AVAILABLE
 INSTANTLY AND SECURELY TO AUTHORIZED USERS.
   (F)  "ELECTRONIC PRESCRIBING SYSTEM" MEANS A SYSTEM THAT ENABLES PRES-
 CRIBERS TO ENTER PRESCRIPTION INFORMATION INTO A  COMPUTER  PRESCRIPTION
 DEVICE  AND  SECURELY  TRANSMIT  THE  PRESCRIPTION TO PHARMACIES USING A
 SPECIAL SOFTWARE PROGRAM AND CONNECTIVITY TO A TRANSMISSION NETWORK.
   (G) "ELECTRONIC PRESCRIPTION"  MEANS  AN  ELECTRONIC  PRESCRIPTION  AS
 DEFINED IN SECTION THIRTY-THREE HUNDRED TWO OF THE PUBLIC HEALTH LAW.
   (H)  "PRESCRIBER"  MEANS  A HEALTH CARE PROVIDER LICENSED TO PRESCRIBE
 MEDICATION OR MEDICAL DEVICES IN THE STATE.
   (I)  "REAL-TIME  BENEFIT  TOOL"  OR   "RTBT"   MEANS   AN   ELECTRONIC
 PRESCRIPTION  DECISION  SUPPORT TOOL THAT: (I) IS CAPABLE OF INTEGRATING
 WITH PRESCRIBERS' ELECTRONIC PRESCRIBING AND,  IF  FEASIBLE,  ELECTRONIC
 HEALTH  RECORD  SYSTEMS;  AND (II) COMPLIES WITH THE TECHNICAL STANDARDS
 ADOPTED BY AN AMERICAN NATIONAL STANDARDS  INSTITUTE  (ANSI)  ACCREDITED
 STANDARDS DEVELOPMENT ORGANIZATION.
   (J)  "AUTHORIZED  THIRD-PARTY"  SHALL  INCLUDE  A  THIRD-PARTY LEGALLY
 AUTHORIZED UNDER STATE OR FEDERAL LAW  SUBJECT  TO  A  HEALTH  INSURANCE
 PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) BUSINESS ASSOCIATE AGREEMENT.
   2.  NO  LATER  THAN JULY FIRST, TWO THOUSAND TWENTY-THREE, EACH HEALTH
 PLAN OPERATING IN THE STATE SHALL, UPON REQUEST OF THE COVERED  INDIVID-
 UAL,  HIS  OR  HER HEALTH CARE PROVIDER, OR AN AUTHORIZED THIRD-PARTY ON
 THEIR BEHALF, FURNISH THE COST, BENEFIT, AND COVERAGE DATA SET FORTH  AS
 REQUIRED  TO THE COVERED INDIVIDUAL, HIS OR HER HEALTH CARE PROVIDER, OR
 THE THIRD-PARTY OF HIS OR HER CHOOSING AND SHALL ENSURE THAT  SUCH  DATA
 IS  (I) CURRENT NO LATER THAN ONE BUSINESS DAY AFTER ANY CHANGE IS MADE;
 (II) PROVIDED IN REAL TIME; AND (III) IN A FORMAT THAT IS EASILY  ACCES-
 SIBLE  TO  THE COVERED INDIVIDUAL, IN THE CASE OF HIS OR HER HEALTH CARE
 PROVIDER, THROUGH AN ELECTRONIC HEALTH RECORDS SYSTEM.
   3. THE FORMAT OF THE REQUEST SHALL USE  ESTABLISHED  INDUSTRY  CONTENT
 AND TRANSPORT STANDARDS PUBLISHED BY:
   (A)  A  STANDARDS  DEVELOPING  ORGANIZATION ACCREDITED BY THE AMERICAN
 NATIONAL STANDARDS INSTITUTE (ANSI), INCLUDING, THE NATIONAL COUNCIL FOR
 PRESCRIPTION DRUG PROGRAMS (NCPDP), ASC X12, HEALTH LEVEL 7; OR
   (B) A RELEVANT FEDERAL OR STATE GOVERNING BODY, INCLUDING  THE  CENTER
 FOR MEDICARE & MEDICAID SERVICES OR THE OFFICE OF THE NATIONAL COORDINA-
 TOR FOR HEALTH INFORMATION TECHNOLOGY; OR
   (C)  ANOTHER FORMAT DEEMED ACCEPTABLE TO THE DEPARTMENT WHICH PROVIDES
 THE DATA PRESCRIBED IN SUBDIVISION TWO OF THIS SECTION AND IN  THE  SAME
 TIMELINESS AS REQUIRED BY THIS SECTION.
   4. A FACSIMILE SHALL NOT BE CONSIDERED AN ACCEPTABLE ELECTRONIC FORMAT
 PURSUANT TO THIS SECTION.
   5.  UPON  SUCH  REQUEST,  THE FOLLOWING DATA SHALL BE PROVIDED FOR ANY
 DRUG COVERED UNDER THE COVERED INDIVIDUAL'S HEALTH PLAN:
   (A) PATIENT-SPECIFIC ELIGIBILITY INFORMATION;
   (B) PATIENT-SPECIFIC PRESCRIPTION  COST  AND  BENEFIT  DATA,  SUCH  AS
 APPLICABLE  FORMULARY,  BENEFIT,  COVERAGE AND COST-SHARING DATA FOR THE
 PRESCRIBED DRUG AND CLINICALLY-APPROPRIATE ALTERNATIVES, WHEN  APPROPRI-
 ATE;
   (C)  PATIENT-SPECIFIC COST-SHARING INFORMATION THAT DESCRIBES VARIANCE
 IN COST-SHARING BASED ON THE PHARMACY DISPENSING THE PRESCRIBED DRUG  OR
 ITS  ALTERNATIVES, AND IN RELATION TO THE PATIENT'S BENEFIT (I.E., SPEND
 RELATED TO OUT-OF-POCKET MAXIMUM);
 S. 4620--C                          3
 
   (D) INFORMATION REGARDING LOWER COST CLINICALLY-APPROPRIATE  TREATMENT
 ALTERNATIVES; AND
   (E) APPLICABLE UTILIZATION MANAGEMENT REQUIREMENTS.
   6.  ANY HEALTH PLAN OR PHARMACY BENEFIT MANAGER SHALL FURNISH THE DATA
 AS REQUIRED WHETHER THE REQUEST IS MADE USING THE DRUG'S UNIQUE  BILLING
 CODE, SUCH AS A NATIONAL DRUG CODE OR HEALTHCARE COMMON PROCEDURE CODING
 SYSTEM  CODE  OR  DESCRIPTIVE  TERM.  A  HEALTH PLAN OR PHARMACY BENEFIT
 MANAGER SHALL NOT DENY OR UNREASONABLY DELAY A REQUEST AS  A  METHOD  OF
 BLOCKING  THE  DATA SET FORTH AS REQUIRED FROM BEING SHARED BASED ON HOW
 THE DRUG WAS REQUESTED.
   7. A HEALTH PLAN OR  PHARMACY  BENEFIT  MANAGER  SHALL  NOT  RESTRICT,
 PROHIBIT,  OR  OTHERWISE  HINDER    THE PRESCRIBER FROM COMMUNICATING OR
 SHARING BENEFIT AND COVERAGE INFORMATION THAT  REFLECTS  OTHER  CHOICES,
 SUCH  AS  CASH  PRICE,  LOWER  COST CLINICALLY-APPROPRIATE ALTERNATIVES,
 WHETHER OR NOT THEY ARE COVERED UNDER  THE  COVERED  INDIVIDUAL'S  PLAN,
 PATIENT  ASSISTANCE  AND  SUPPORT PROGRAMS AND THE COST AVAILABLE AT THE
 PATIENT'S PHARMACY OF CHOICE.
   8. A HEALTH PLAN OR PHARMACY BENEFIT MANAGER SHALL NOT, EXCEPT AS  MAY
 BE  REQUIRED  BY  LAW, INTERFERE WITH, PREVENT, OR MATERIALLY DISCOURAGE
 ACCESS, EXCHANGE, OR USE OF THE DATA  AS  REQUIRED,  WHICH  MAY  INCLUDE
 CHARGING FEES, OR NOT RESPONDING TO A REQUEST FOR SUCH DATA IN A REASON-
 ABLE TIME FRAME; NOR PENALIZE A HEALTH CARE PROVIDER OR PROFESSIONAL FOR
 DISCLOSING SUCH INFORMATION TO A COVERED INDIVIDUAL OR LEGALLY PRESCRIB-
 ING,  ADMINISTERING,  OR ORDERING A CLINICALLY APPROPRIATE OR LOWER-COST
 ALTERNATIVE.
   9. NOTHING IN THIS SECTION SHALL BE CONSTRUED TO LIMIT ACCESS  TO  THE
 MOST   UP-TO-DATE   PATIENT-SPECIFIC   ELIGIBILITY  OR  PATIENT-SPECIFIC
 PRESCRIPTION COST AND BENEFIT DATA BY THE HEALTH PLAN.
   10. NOTHING IN THIS SECTION SHALL INTERFERE WITH PATIENT CHOICE AND  A
 HEALTH   CARE  PROFESSIONAL'S  ABILITY  TO  CONVEY  THE  FULL  RANGE  OF
 PRESCRIPTION DRUG COST OPTIONS TO A PATIENT.  HEALTH PLANS  OR  PHARMACY
 BENEFIT  MANAGERS  SHALL  NOT  RESTRICT  A HEALTH CARE PROFESSIONAL FROM
 COMMUNICATING TO THE PATIENT PRESCRIPTION COST OPTIONS.
   11. NO RTBT SHALL REQUIRE A PATIENT TO UTILIZE SPECIFIC PLAN PREFERRED
 DRUGS OR PHARMACIES.
   § 3.  Severability. If any provision of this act, or  any  application
 of  any  provision of this  act, is held to be invalid, or to violate or
 be inconsistent with any   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,  which
 can  be given effect  without that provision or application; and to that
 end, the provisions  and applications of this act are severable.
   § 4. This act shall take effect one hundred eighty days after it shall
 have become a law. Effective immediately, the addition, amendment and/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 effective date.

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The New York State Senate

senate Bill S4620C

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Archive: Last Bill Status - Signed by Governor

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Votes

May 24, 2022 - floor Vote

Floor Vote: May 24, 2022

May 23, 2022 - Rules committee Vote

Rules Committee Vote: May 23, 2022

Bill Amendments

S4620 - Details

S4620 - Summary

S4620 - Sponsor Memo

S4620 - Bill Text download pdf

S4620A - Details

S4620A - Summary

S4620A - Sponsor Memo

S4620A - Bill Text download pdf

S4620B - Details

S4620B - Summary

S4620B - Sponsor Memo

S4620B - Bill Text download pdf

S4620C (ACTIVE) - Details

S4620C (ACTIVE) - Summary

S4620C (ACTIVE) - Sponsor Memo

S4620C (ACTIVE) - Bill Text download pdf

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senate Bill S4620C

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Sponsored By

Neil D. Breslin

Archive: Last Bill Status - Signed by Governor

Your Voice

Actions

Votes

May 24, 2022 - floor Vote

Floor Vote: May 24, 2022

May 23, 2022 - Rules committee Vote

Rules Committee Vote: May 23, 2022

Bill Amendments

S4620 - Details

S4620 - Summary

S4620 - Sponsor Memo

S4620 - Bill Text download pdf

S4620A - Details

S4620A - Summary

S4620A - Sponsor Memo

S4620A - Bill Text download pdf

S4620B - Details

S4620B - Summary

S4620B - Sponsor Memo

S4620B - Bill Text download pdf

S4620C (ACTIVE) - Details

S4620C (ACTIVE) - Summary

S4620C (ACTIVE) - Sponsor Memo

S4620C (ACTIVE) - Bill Text download pdf

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