Current through 2024 NY Law Chapters 1-50, 52-55, 57, 61-117
Section 341-A - [Effective and Repealed Effective 6/28/2023] Patient prescription pricing transparency1. Definitions. As used in this section: (a) The terms "covered individual", "health plan", and "pharmacy benefit 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 necessary 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 prescribers 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 individual, 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 accessible 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 Coordinator 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 appropriate;(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(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 reasonable time frame; nor penalize a health care provider or professional for disclosing such information to a covered individual or legally prescribing, 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.Repealed by New York Laws 2023, ch. 63,Sec. 1, eff. 6/28/2023.Added by New York Laws 2022, ch. 826,Sec. 2, eff. 6/28/2023.