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This entry was published on 2014-09-22
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Pharmaceutical insurance contract
§ 243. Pharmaceutical insurance contract. 1. The commissioner of
health shall, subject to the approval of the director of the budget,
enter into a contract with one or more contractors to assist in carrying
out the provisions of this title. Such contractual arrangements shall be
made subject to a competitive process pursuant to the state finance law
and shall ensure that state payments for the contractor's necessary and
legitimate expenses for the administration of this program are limited
to the amount specified in advance, and that such payments shall not
exceed the amount appropriated therefor in any fiscal year. The
commissioner shall review the contract pricing provisions to assure that
the level of contract payments are in the best interest of the state,
giving consideration to the total level of participant enrollment
achieved, the volume of claims processed, and such other factors as may
be relevant in order to contain state expenditures. In the event that
the commissioner determines that the contract payment provisions do not
protect the interest of the state, the commissioner shall initiate
contract negotiations for the purpose of modifying contract payments
and/or scope requirements.

2. The responsibilities of the contractor or contractors shall
include, but need not be limited to:

(a) providing for a method of determining, on an annual basis and upon
their application therefor, the eligibility of persons pursuant to
section two hundred forty-two of this title within a reasonable period
of time, including alternative methods for such determination of
eligibility, such as through the mail or home visits, where reasonable
and/or necessary, and for notifying applicants of such eligibility

(b) notifying each eligible program participant in writing upon the
commencement of the annual coverage period of such participant's
cost-sharing responsibilities pursuant to section two hundred
forty-seven of this title. The contractor shall also notify each
eligible program participant of any adjustment of the co-payment
schedule by mail no less than thirty days prior to the effective date of
such adjustments and shall inform such eligible program participants of
the date such adjustments shall take effect;

(c) issuing an identification card to each eligible program

(d) processing of claims for reimbursement to participating provider
pharmacies pursuant to section two hundred fifty of this title;

(e) performing or causing to be performed utilization reviews for such
purposes as may be required by the commissioner of health;

(f) conducting audits and surveys of participating provider pharmacies
as specified pursuant to the terms and conditions of the contract; and

(g) coordinating coverage with insurance companies and other public
and private organizations offering such coverage for those eligible
program participants having partial coverage for covered drugs through
third-party sources, and providing for recoupment of any duplicate
reimbursement paid by the state on behalf of such eligible program

3. The contractor or contractors shall be required to provide such
reports as may be deemed necessary by the commissioner of health and
shall maintain files in a manner and format approved by the

4. The contractor or contractors may contract with private
not-for-profit or proprietary corporations, or with entities of local
government within the state of New York, to perform such obligations of
the contractor or contractors as the commissioner of health shall