S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   7357
 
                        2025-2026 Regular Sessions
 
                           I N  A S S E M B L Y
 
                              March 25, 2025
                                ___________
 
 Introduced  by M. of A. PRETLOW -- read once and referred to the Commit-
   tee on Health
 
 AN ACT to amend the public health law and the insurance law, in relation
   to pharmacy benefit management services and durable medical equipment
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section  1.  Subdivisions 1, 3, 4 and 5 of section 280-a of the public
 health law, subdivisions 1 and 3 as amended by chapter 128 of  the  laws
 of  2022, subdivision 4 as added by chapter 828 of the laws of 2021, and
 subdivision 5 as amended by chapter 396 of the laws of 2024, are amended
 to read as follows:
   1. Definitions. As used in this section,  the  following  terms  shall
 have the following meanings:
   (a) "Health plan" means an entity for which a pharmacy benefit manager
 provides pharmacy benefit management services and that is a health bene-
 fit  plan or other entity that approves, provides, arranges for, or pays
 or reimburses in whole or in part for health care items or services,  to
 include  at least prescription drugs OR DURABLE MEDICAL EQUIPMENT, for a
 substantial number of beneficiaries who work or reside  in  this  state.
 The  superintendent  shall  determine,  in [his or her] SUCH SUPERINTEN-
 DENT'S sole discretion, by regulation  how  the  phrase  "a  substantial
 number  of  beneficiaries  who  work  or  reside in this state" shall be
 interpreted.
   (b) "Pharmacy benefit management services"  means  the  management  or
 administration  of  prescription  drug  benefits    OR THE MANAGEMENT OR
 ADMINISTRATION OF BENEFITS RELATING TO DURABLE MEDICAL EQUIPMENT, for  a
 health  plan,  directly  or  through  another  entity, and regardless of
 whether the pharmacy benefit manager and the health plan are related, or
 associated by ownership, common ownership,  organization  or  otherwise;
 including  the  procurement  of  prescription  drugs  to be dispensed to
 patients, [or] the administration or  management  of  prescription  drug
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD10971-01-5
              

 A. 7357                             2
 
 benefits,  OR  THE  ADMINISTRATION OR MANAGEMENT OF BENEFITS RELATING TO
 DURABLE MEDICAL EQUIPMENT, including but not  limited  to,  any  of  the
 following:
   (i) mail service pharmacy;
   (ii)  claims  processing,  retail  network  management,  or payment of
 claims to pharmacies for dispensing prescription drugs;
   (iii) clinical or other formulary or preferred drug  list  development
 or management;
   (iv)  negotiation  or  administration  of  rebates, discounts, payment
 differentials, or other incentives,  for  the  inclusion  of  particular
 prescription  drugs  in a particular category or to promote the purchase
 of particular prescription drugs;
   (v) patient compliance, therapeutic intervention, or  generic  substi-
 tution programs;
   (vi) disease management;
   (vii) drug utilization review or prior authorization;
   (viii)  adjudication  of appeals or grievances related to prescription
 drug coverage;
   (ix) contracting with network pharmacies; [and]
   (x) controlling the cost of covered prescription drugs; AND
   (XI) CREDENTIALING, CONTRACTING, AUTHORIZING, PROCESSING  PAYMENT,  OR
 ACTING  AS  AN  INTERMEDIARY  FOR  THE  MANAGEMENT,  ADMINISTRATION,  OR
 PROVISION OF DURABLE MEDICAL EQUIPMENT, EXCLUDING WORKERS'  COMPENSATION
 PLANS.
   (c) "Pharmacy benefit manager" means any entity that performs pharmacy
 benefit management services for a health plan.
   (d)  "Maximum  allowable  cost  price"  means  a maximum reimbursement
 amount set by the pharmacy benefit manager  for  therapeutically  equiv-
 alent multiple source generic drugs.
   (e) "Controlling person" means any person or other entity who or which
 directly  or  indirectly has the power to direct or cause to be directed
 the management, control or activities of a pharmacy benefit manager.
   (f)  "Covered  individual"  means  a  member,  participant,  enrollee,
 contract holder or policy holder or beneficiary of a health plan.
   (g)  "License" means a license to be a pharmacy benefit manager, under
 article twenty-nine of the insurance law.
   (h) "Spread pricing" means the practice of a pharmacy benefit  manager
 retaining  an  additional amount of money in addition to the amount paid
 to the  pharmacy  OR  DURABLE  MEDICAL  EQUIPMENT  PROVIDER  to  fill  a
 prescription.
   (i) "Superintendent" means the superintendent of financial services.
   (J)  "DURABLE MEDICAL EQUIPMENT" MEANS DEVICES AND EQUIPMENT THAT HAVE
 BEEN ORDERED BY A PRACTITIONER IN THE TREATMENT OF  A  SPECIFIC  MEDICAL
 CONDITION AND THAT HAVE ALL OF THE FOLLOWING CHARACTERISTICS:
   (I) CAN WITHSTAND REPEATED USE FOR A PROTRACTED PERIOD OF TIME;
   (II) ARE PRIMARILY AND CUSTOMARILY USED FOR MEDICAL PURPOSES;
   (III) ARE GENERALLY NOT USEFUL IN THE ABSENCE OF AN ILLNESS OR INJURY;
   (IV)  ARE  NOT  USUALLY FITTED, DESIGNED OR FASHIONED FOR A PARTICULAR
 INDIVIDUAL'S USE; AND
   (V) IF INTENDED FOR USE BY ONLY ONE  PATIENT,  THE  EQUIPMENT  MAY  BE
 EITHER CUSTOM-MADE OR CUSTOMIZED.
   THE    TERM   "DURABLE   MEDICAL   EQUIPMENT"   SHALL   ALSO   INCLUDE
 MEDICAL/SURGICAL  SUPPLIES,  ORTHOTIC  APPLIANCES   AND   DEVICES,   AND
 ORTHOPEDIC FOOTWEAR, AS DEFINED BY THE COMMISSIONER.
   3.  Prescriptions.  A  pharmacy  benefit manager may not substitute or
 cause the substituting of one  prescription  drug  OR  ITEM  OF  DURABLE
 A. 7357                             3
 
 MEDICAL  EQUIPMENT for another in dispensing a prescription, or alter or
 cause the altering of the terms  of  a  prescription,  except  with  the
 approval  of  the  prescriber  or as explicitly required or permitted by
 law,  including  regulations  of the department of financial services or
 the department of health. The superintendent and commissioner, in  coor-
 dination  with  each  other, are authorized to promulgate regulations to
 determine when substitution of prescription  drugs  OR  DURABLE  MEDICAL
 EQUIPMENT may be required or permitted.
   4.  Appeals.  A  pharmacy  benefit  manager  shall,  with  respect  to
 contracts between a pharmacy benefit manager and a pharmacy  OR  DURABLE
 MEDICAL EQUIPMENT PROVIDER or, alternatively, a pharmacy benefit manager
 and  a  [pharmacy's]  contracting agent OF A PHARMACY OR DURABLE MEDICAL
 EQUIPMENT PROVIDER, such as a pharmacy services administrative organiza-
 tion, include a reasonable process to appeal,  investigate  and  resolve
 disputes  regarding multi-source generic drug pricing. The appeals proc-
 ess shall include the following provisions:
   (a) the right to appeal by the  pharmacy,  DURABLE  MEDICAL  EQUIPMENT
 PROVIDER,  and/or  the [pharmacy's] contracting agent OF THE PHARMACY OR
 DURABLE MEDICAL EQUIPMENT PROVIDER  shall  be  limited  to  thirty  days
 following the initial claim submitted for payment;
   (b)  a  telephone  number  through which a network pharmacy OR DURABLE
 MEDICAL EQUIPMENT PROVIDER may contact the pharmacy benefit manager  for
 the  purpose  of  filing an appeal and an electronic mail address of the
 individual who is responsible for processing appeals;
   (c) the pharmacy benefit manager shall send an electronic mail message
 acknowledging receipt of the appeal. The pharmacy benefit manager  shall
 respond in an electronic message to the pharmacy, DURABLE MEDICAL EQUIP-
 MENT PROVIDER, and/or the [pharmacy's] contracting agent OF THE PHARMACY
 OR  DURABLE  MEDICAL  EQUIPMENT  PROVIDER filing the appeal within seven
 business days indicating its determination. If the appeal is  determined
 to  be  valid, the maximum allowable cost for the drug shall be adjusted
 for the appealing pharmacy OR DURABLE MEDICAL EQUIPMENT PROVIDER  effec-
 tive  as  of  the  date  of the original claim for payment. The pharmacy
 benefit manager shall require the appealing pharmacy OR DURABLE  MEDICAL
 EQUIPMENT  PROVIDER to reverse and rebill the claim in question in order
 to obtain the corrected reimbursement;
   (d) if an update to the maximum allowable cost is warranted, the phar-
 macy benefit manager or covered entity shall adjust the  maximum  allow-
 able cost of the drug effective for all similarly situated pharmacies in
 its  network  in  the  state on the date the appeal was determined to be
 valid; and
   (e) if an appeal is denied, the pharmacy benefit manager shall identi-
 fy the national drug code  of  a  therapeutically  equivalent  drug,  as
 determined  by  the federal Food and Drug Administration, that is avail-
 able for purchase by pharmacies in this state  from  wholesalers  regis-
 tered  pursuant to subdivision four of section sixty-eight hundred eight
 of the education law at a price which is equal to or less than the maxi-
 mum allowable cost for that drug as determined by the  pharmacy  benefit
 manager.
   5.  Contract  provisions.  No  pharmacy  benefit  manager  shall, with
 respect to contracts between such pharmacy benefit manager and a PHARMA-
 CY OR DURABLE MEDICAL EQUIPMENT  PROVIDER  pharmacy  or,  alternatively,
 such  pharmacy benefit manager and a [pharmacy's] contracting agent OF A
 PHARMACY OR DURABLE MEDICAL  EQUIPMENT  PROVIDER,  such  as  a  pharmacy
 services administrative organization:
 A. 7357                             4
 
   (a)  prohibit  or  penalize  a  pharmacist  [or], pharmacy, OR DURABLE
 MEDICAL EQUIPMENT PROVIDER from disclosing to an  individual  purchasing
 [a]  prescription  medication,  DURABLE  MEDICAL EQUIPMENT, or A service
 information regarding:
   (i)  the  cost  of the prescription medication, DURABLE MEDICAL EQUIP-
 MENT, or service to the individual, or  the  cost  of  the  prescription
 medication,  DURABLE  MEDICAL  EQUIPMENT,  or service to the pharmacy OR
 DURABLE MEDICAL EQUIPMENT PROVIDER and the [pharmacy's] reimbursement TO
 SUCH  PHARMACY  OR  DURABLE  MEDICAL   EQUIPMENT   PROVIDER   for   that
 prescription medication, DURABLE MEDICAL EQUIPMENT, or service; or
   (ii)  the  availability  of any therapeutically equivalent alternative
 medications or alternative methods of purchasing the prescription  medi-
 cation  OR  DURABLE  MEDICAL  EQUIPMENT,  including  but not limited to,
 paying a cash price; or
   (b) charge or collect from an individual a copayment that exceeds  the
 total  submitted  charges  by  the pharmacy OR DURABLE MEDICAL EQUIPMENT
 PROVIDER for which the pharmacy OR DURABLE MEDICAL EQUIPMENT PROVIDER is
 paid.   If an individual pays  a  copayment,  the  pharmacy  OR  DURABLE
 MEDICAL  EQUIPMENT  PROVIDER  shall retain the adjudicated costs and the
 pharmacy benefit manager shall not  redact  or  recoup  the  adjudicated
 cost.
   § 2.  Section 280-c of the public health law, as added by section 1 of
 part  MM  of  chapter  57  of  the  laws  of 2018, is amended to read as
 follows:
   § 280-c. Pharmacy OR DURABLE  MEDICAL  EQUIPMENT  PROVIDER  audits  by
 pharmacy benefit managers. 1. Definitions.  As used in this section, the
 following terms shall have the following meanings:
   (a)  "Pharmacy  benefit  manager"  shall  have  the same meaning as in
 section two hundred eighty-a of this article.
   (b) "Pharmacy" shall mean a pharmacy that has contracted with a  phar-
 macy benefit manager for the provision of pharmacy services.
   (C)  "DURABLE  MEDICAL  EQUIPMENT"  SHALL  HAVE THE SAME MEANING AS IN
 SECTION TWO HUNDRED EIGHTY-A OF THIS ARTICLE.
   2. When conducting an audit of a pharmacy's OR DURABLE MEDICAL  EQUIP-
 MENT PROVIDER'S records, a pharmacy benefit manager shall:
   (a)  not  conduct  an  on-site  audit of a pharmacy OR DURABLE MEDICAL
 EQUIPMENT PROVIDER at any time during the first three calendar days of a
 month;
   (b) notify the pharmacy, DURABLE MEDICAL EQUIPMENT PROVIDER  or  [its]
 THE  contracting  agent  OF  SUCH  PHARMACY OR DURABLE MEDICAL EQUIPMENT
 PROVIDER no later than fifteen days before the date of  initial  on-site
 audit.  Such  notification  to  the  pharmacy, DURABLE MEDICAL EQUIPMENT
 PROVIDER or [its] THE contracting agent  OF  SUCH  PHARMACY  OR  DURABLE
 MEDICAL  EQUIPMENT  PROVIDER shall be in writing delivered either (i) by
 mail or common carrier, return receipt requested, or (ii) electronically
 with electronic receipt confirmation, addressed to the supervising phar-
 macist of record and pharmacy corporate office, OR THE  DURABLE  MEDICAL
 EQUIPMENT  PROVIDER,  where applicable, at least fifteen days before the
 date of an initial on-site audit;
   (c) limit the audit period to twenty-four  months  after  the  date  a
 claim is submitted to or adjudicated by the pharmacy benefit manager;
   (d) include in the written advance notice of an on-site audit the list
 of specific prescription numbers to be included in the audit that may or
 may not include the final two digits of the prescription numbers;
   (e) use the written and verifiable records of a hospital, physician or
 other  authorized  practitioner,  which  are transmitted by any means of
 A. 7357                             5
 
 communication, to validate the pharmacy  OR  DURABLE  MEDICAL  EQUIPMENT
 PROVIDER records in accordance with state and federal law;
   (f)  limit  the  number  of  prescriptions audited to no more than one
 hundred randomly selected in a twelve-month period, except in  cases  of
 fraud;
   (g)  provide the pharmacy, DURABLE MEDICAL EQUIPMENT PROVIDER or [its]
 THE contracting agent OF SUCH  PHARMACY  OR  DURABLE  MEDICAL  EQUIPMENT
 PROVIDER  with  a copy of the preliminary audit report within forty-five
 days after the conclusion of the audit;
   (h) be allowed to conduct a follow-up audit on-site  if  a  remote  or
 desk audit reveals the necessity for a review of additional claims;
   (i)  in the case of invoice audits, accept as validation invoices from
 any wholesaler registered with the department of  education  from  which
 the  pharmacy  OR  DURABLE  MEDICAL  EQUIPMENT  PROVIDER  has  purchased
 prescription drugs or, in the case of durable medical equipment or sick-
 room supplies, invoices from an  authorized  distributor  other  than  a
 wholesaler;
   (j)  provide the pharmacy, DURABLE MEDICAL EQUIPMENT PROVIDER or [its]
 THE contracting agent OF SUCH  PHARMACY  OR  DURABLE  MEDICAL  EQUIPMENT
 PROVIDER with the ability to provide documentation to address a discrep-
 ancy or audit finding, provided that such documentation must be received
 by  the pharmacy benefit manager no later than the forty-fifth day after
 the preliminary audit report  was  provided  to  the  pharmacy,  DURABLE
 MEDICAL  EQUIPMENT PROVIDER or [its] THE contracting agent OF SUCH PHAR-
 MACY OR DURABLE MEDICAL EQUIPMENT PROVIDER.  The pharmacy benefit manag-
 er shall consider a reasonable request  from  the  pharmacy  OR  DURABLE
 MEDICAL EQUIPMENT PROVIDER for an extension of time to submit documenta-
 tion to address or correct any findings in the report; and
   (k) provide the pharmacy, DURABLE MEDICAL EQUIPMENT PROVIDER, or [its]
 THE  contracting  agent  OF  SUCH  PHARMACY OR DURABLE MEDICAL EQUIPMENT
 PROVIDER with the final audit report no later than sixty days after  the
 initial  audit  report  was  provided  to  the pharmacy, DURABLE MEDICAL
 EQUIPMENT PROVIDER, or [its] THE contracting agent OF SUCH  PHARMACY  OR
 DURABLE MEDICAL EQUIPMENT PROVIDER.
   3. Any claim that was retroactively denied for a clerical error, typo-
 graphical  error,  scrivener's  error or computer error shall be paid if
 the prescription was properly and correctly dispensed, unless a  pattern
 of  such  errors  exists,  fraudulent  billing  is  alleged or the error
 results in actual financial loss to the entity. A clerical error  is  an
 error that does not result in actual financial harm to the covered enti-
 ty or consumer and does not include the dispensing of an incorrect dose,
 amount  or type of medication or dispensing a prescription drug OR DURA-
 BLE MEDICAL EQUIPMENT to the wrong person.
   4. This section shall not apply to:
   (a) audits in which suspected fraudulent activity or other intentional
 or willful misrepresentation is evidenced by a physical  review,  review
 of claims data or statements, or other investigative methods; or
   (b) audits of claims paid for by federally funded programs; or
   (c) concurrent reviews or desk audits that occur within three business
 days of transmission of a claim and where no chargeback or recoupment is
 demanded.
   §  3.  Paragraph 2 of subsection (a) of section 111-a of the insurance
 law, as added by chapter 738 of the laws of 2023, is amended to read  as
 follows:
   (2)  A  pharmacy benefit manager, including an entity that directly or
 through an intermediary, manages the prescription drug coverage provided
 A. 7357                             6
 
 by a health insurer under a contract or policy delivered or  issued  for
 delivery in this state or a health plan subject to section three hundred
 sixty-four-j  of  the  social services law, including the processing and
 payment of claims for prescription drugs, the performance of drug utili-
 zation  review, the processing of drug prior authorization requests, the
 adjudication of appeals  or  grievances  related  to  prescription  drug
 coverage,  contracting with network pharmacies, and controlling the cost
 of covered prescription drugs, BUT  NOT  INCLUDING  A  PHARMACY  BENEFIT
 MANAGER ENGAGED SOLELY IN CREDENTIALING, CONTRACTING, AUTHORIZING, PROC-
 ESSING  PAYMENT, OR ACTING AS AN INTERMEDIARY FOR THE MANAGEMENT, ADMIN-
 ISTRATION, OR  PROVISION  OF  DURABLE  MEDICAL  EQUIPMENT,  PROSTHETICS,
 ORTHOTICS OR SUPPLIES.
   §  4.  Subsection (b) of section 2901 of the insurance law, as amended
 by chapter 128 of the laws of 2022, is amended to read as follows:
   (b) The terms "covered individual", "health plan",  "pharmacy  benefit
 manager",  [and]  "pharmacy  benefit  management services", AND "DURABLE
 MEDICAL EQUIPMENT" 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.
   § 5. Subsection (b) of section 2902 of the insurance law,  as  amended
 by chapter 128 of the laws of 2022, is amended to read as follows:
   (b)  Any  person,  firm, association, corporation or other entity that
 violates this section shall, in addition to any other  penalty  provided
 by law, be liable for restitution and compensatory damages to any health
 plan,  pharmacy,  DURABLE MEDICAL EQUIPMENT PROVIDER, [or] covered indi-
 vidual, or other person harmed  by  the  violation  and  shall  also  be
 subject  to  a penalty not exceeding of the greater of (1) four thousand
 dollars for the first violation and ten thousand dollars for each subse-
 quent violation or (2) the aggregate economic gross  receipts  attribut-
 able to all violations.
   §  6.  Subsection (b) of section 2905 of the insurance law, as amended
 by chapter 128 of the laws of 2022, is amended to read as follows:
   (b) Any person, firm, association, corporation or  other  entity  that
 violates  this  section shall, in addition to any other penalty provided
 by law, be liable for restitution and compensatory damages to any health
 plan, pharmacy, DURABLE MEDICAL EQUIPMENT PROVIDER,  covered  individual
 or  other person harmed by the violation and further shall be subject to
 a penalty not exceeding the greater of (1) four thousand dollars for the
 first violation and ten thousand dollars for each  subsequent  violation
 or  (2)  the  aggregate  economic  gross  receipts  attributable  to all
 violations, as determined by the superintendent at a hearing.
   § 7. Paragraph 6 of subsection (b) of section 2906  of  the  insurance
 law,  as added by chapter 128 of the laws of 2022, is amended to read as
 follows:
   (6) standards and practices used in the creation of pharmacy  networks
 AND  DURABLE  MEDICAL  EQUIPMENT  PROVIDER NETWORKS and contracting with
 network pharmacies,  DURABLE  MEDICAL  EQUIPMENT  PROVIDERS,  and  other
 providers,  including  promotion  and  use  of independent and community
 pharmacies and patient access and minimizing excessive concentration and
 vertical integration of markets; and
   § 8. Paragraph 1 of subsection (g) of section 3217-a of the  insurance
 law is amended by adding a new subparagraph (J) to read as follows:
   (J)  "DURABLE  MEDICAL  EQUIPMENT"  SHALL  HAVE THE SAME MEANING AS IN
 SECTION TWO HUNDRED EIGHTY-A OF THE PUBLIC HEALTH LAW.
 A. 7357                             7

   § 9. Subparagraph (B) of paragraph 1, and paragraphs 6, 7  and  10  of
 subsection (g) of section 3217-a of the insurance law, as added by chap-
 ter 63 of the laws of 2023, are amended to read as follows:
   (B) "Cost-sharing information" means the amount an insured is required
 to  pay  to  receive a drug OR ITEM OF DURABLE MEDICAL EQUIPMENT that is
 covered under the insured's insurance policy.
   (6)  Upon  a  request  made  pursuant  to  paragraph  three  of   this
 subsection,  the  insurer  or pharmacy benefit manager shall provide the
 following data for any drug OR DURABLE MEDICAL EQUIPMENT  covered  under
 the insured's insurance policy:
   (A) insured-specific eligibility information;
   (B)  insured-specific  prescription  cost  and  benefit  data, such as
 applicable formulary, benefit, coverage and cost-sharing  data  for  the
 prescribed  drug  and  clinically-appropriate  alternatives  OR  DURABLE
 MEDICAL EQUIPMENT, when appropriate;
   (C) insured-specific cost-sharing information that describes  variance
 in  cost-sharing  based  on  the  pharmacy  OR DURABLE MEDICAL EQUIPMENT
 PROVIDER dispensing the prescribed drug or its alternatives  OR  DURABLE
 MEDICAL EQUIPMENT, and in relation to the insured's benefit; and
   (D) applicable utilization management requirements.
   (7)  Any insurer or pharmacy benefit manager shall furnish the data as
 required whether the request is made using the [drug's]  unique  billing
 code  OF  THE DRUG OR DURABLE MEDICAL EQUIPMENT, such as a National Drug
 Code or Healthcare Common Procedure Coding System  code  or  descriptive
 term. An insurer or pharmacy benefit manager shall not deny or unreason-
 ably delay processing a request.
   (10)  Nothing  in  this subsection shall interfere with insured choice
 and a health care  provider's  ability  to  convey  the  full  range  of
 prescription  drug  OR  DURABLE  MEDICAL  EQUIPMENT  cost  options to an
 insured. Insurers and pharmacy benefit managers  shall  not  restrict  a
 health care provider from communicating to the insured prescription cost
 options.
   §  10.  Paragraph 1 of subsection (g) of section 4324 of the insurance
 law is amended by adding a new subparagraph (J) to read as follows:
   (J) "DURABLE MEDICAL EQUIPMENT" SHALL HAVE  THE  SAME  MEANING  AS  IN
 SECTION TWO HUNDRED EIGHTY-A OF THE PUBLIC HEALTH LAW.
   §  11.  Subparagraph (B) of paragraph 1, and paragraphs 6, 7 and 10 of
 subsection (g) of section 4324 of the insurance law, as added by chapter
 63 of the laws of 2023, are amended to read as follows:
   (B) "Cost-sharing  information"  means  the  amount  a  subscriber  is
 required  to  pay to receive a drug OR AN ITEM OF DURABLE MEDICAL EQUIP-
 MENT that is covered under the subscriber's insurance contract.
   (6)  Upon  a  request  made  pursuant  to  paragraph  three  of   this
 subsection,  the  health  service,  hospital service, or medical expense
 indemnity corporation or pharmacy  benefit  manager  shall  provide  the
 following  data  for any drug OR DURABLE MEDICAL EQUIPMENT covered under
 the subscriber's insurance contract:
   (A) subscriber-specific eligibility information;
   (B) subscriber-specific prescription cost and benefit  data,  such  as
 applicable  formulary,  benefit, coverage, and cost-sharing data for the
 prescribed  drug  and  clinically-appropriate  alternatives  OR  DURABLE
 MEDICAL EQUIPMENT, when appropriate;
   (C)  subscriber-specific cost-sharing information that describes vari-
 ance in cost-sharing based on the pharmacy OR DURABLE MEDICAL  EQUIPMENT
 PROVIDER  dispensing  the prescribed drug or its alternatives OR DURABLE
 MEDICAL EQUIPMENT, and in relation to the insured's benefit; and
 A. 7357                             8
 
   (D) applicable utilization management requirements.
   (7)  A  health service, hospital service, or medical expense indemnity
 corporation or pharmacy  benefit  manager  shall  furnish  the  data  as
 required  whether  the request is made using the [drug's] unique billing
 code OF THE DRUG OR DURABLE MEDICAL EQUIPMENT, such as a  National  Drug
 Code  or  Healthcare  Common Procedure Coding System code or descriptive
 term. A health service, hospital service, or medical  expense  indemnity
 corporation  or  pharmacy benefit manager shall not deny or unreasonably
 delay processing a request.
   (10) Nothing in this subsection shall interfere with subscriber choice
 and a health care  provider's  ability  to  convey  the  full  range  of
 prescription  drug  OR  DURABLE  MEDICAL  EQUIPMENT  cost  options  to a
 subscriber. Health service, hospital service, or medical expense  indem-
 nity  corporations  and  pharmacy  benefit managers shall not restrict a
 health care provider from communicating to the  subscriber  prescription
 cost options.
   §  12.  Paragraph  (a)  of subdivision 8 of section 4408 of the public
 health law is amended by adding  a  new  subparagraph  (x)  to  read  as
 follows:
   (X)  "DURABLE  MEDICAL  EQUIPMENT"  SHALL  HAVE THE SAME MEANING AS IN
 SECTION TWO HUNDRED EIGHTY-A OF THE PUBLIC HEALTH LAW.
   § 13. Subparagraph (ii) of paragraph (a), and paragraphs (f), (g)  and
 (j)  of subdivision 8 of section 4408 of the public health law, as added
 by chapter 63 of the laws of 2023, are amended to read as follows:
   (ii) "Cost-sharing information"  means  the  amount  a  subscriber  is
 required  to  pay to receive a drug OR AN ITEM OF DURABLE MEDICAL EQUIP-
 MENT that is covered under the subscriber's insurance contract.
   (f) Upon a request made pursuant to paragraph (c) of this subdivision,
 the health maintenance organization or pharmacy  benefit  manager  shall
 provide  the  following  data  for any drug OR DURABLE MEDICAL EQUIPMENT
 covered under the subscriber's subscriber contract:
   (i) subscriber-specific eligibility information;
   (ii) subscriber-specific prescription cost and benefit data,  such  as
 applicable  formulary,  benefit, coverage, and cost-sharing data for the
 prescribed  drug  and  clinically-appropriate  alternatives  OR  DURABLE
 MEDICAL EQUIPMENT, when appropriate;
   (iii)  subscriber-specific  cost-sharing  information  that  describes
 variance in cost-sharing based on the pharmacy OR DURABLE MEDICAL EQUIP-
 MENT PROVIDER dispensing the prescribed  drug  or  its  alternatives  OR
 DURABLE MEDICAL EQUIPMENT, and in relation to the insured's benefit; and
   (iv) applicable utilization management requirements.
   (g)  A  health  maintenance  organization  or pharmacy benefit manager
 shall furnish the data as required whether the request is made using the
 [drug's] unique billing code OF THE DRUG OR DURABLE  MEDICAL  EQUIPMENT,
 such  as  a  National  Drug  Code  or Healthcare Common Procedure Coding
 System code or descriptive term. A health  maintenance  organization  or
 pharmacy benefit manager shall not deny or unreasonably delay processing
 a request.
   (j) Nothing in this subdivision shall interfere with subscriber choice
 and  a  health  care  provider's  ability  to  convey  the full range of
 prescription drug  OR  DURABLE  MEDICAL  EQUIPMENT  cost  options  to  a
 subscriber. Health maintenance organizations and pharmacy benefit manag-
 ers  shall not restrict a health care provider from communicating to the
 subscriber prescription cost options.
   § 14. This act shall take effect immediately.