N.Y. Comp. Codes R. & Regs. tit. 11 § 456.2

Current through Register Vol. 46, No. 53, December 31, 2024

Section 456.2 - Pharmacy contract standards for pharmacy benefit managers

(a) A pharmacy benefit manager shall not, by pharmacy contract or otherwise:

(1) reimburse an in-network pharmacy an amount that is less than what an affiliated pharmacy that is within the same network is reimbursed for providing the same covered services. Nothing in this paragraph shall be construed to limit the ability of a health plan to maintain multiple networks in which reimbursements are different for providing different services, including specialty or mail-order networks;

(2) retroactively deny or reduce any reimbursement for a claim after adjudicating a claim and returning a paid claim response unless:

(i) the claim was submitted fraudulently;

(ii) done to correct pharmacy errors identified in an audit; or

(iii) an adjustment was agreed upon by the pharmacy prior to the denial or reduction;

(3) prohibit a pharmacy from communicating about the pharmacy benefit manager with elected officials or a governmental agency, in any manner, including in a public forum, even if the statements made could reasonably be held to reflect negatively on the pharmacy benefit manager, provided however that nothing in this section shall authorize a pharmacy to:

(i) discuss information that is confidential or constitutes a trade secret; or

(ii) make a false statement of fact.

(4) prohibit, restrict, or limit disclosure of information by a pharmacy to the superintendent; or

(5) arbitrarily, unfairly, or deceptively reduce, rescind, or otherwise claw back any reimbursement payment, in whole or in part, to a pharmacy for a prescription drug's ingredient cost or dispensing fee.

(b) A pharmacy benefit manager shall:

(1) allow a pharmacy to submit electronically all documents and information required as part of any application for participation in a pharmacy network and, to the extent consistent with applicable law, allow for the use of electronic signatures for such enrollment or participation;

(2) mail or deliver a copy of all pharmacy contracts directly to the effected pharmacy, in a manner mutually agreed by the pharmacy and the pharmacy benefit manager, on or prior to the effective date of such pharmacy contract, regardless of whether the pharmacy benefit manager also requires a pharmacy services administrative organization or other contracting agent to transmit such pharmacy contract to the pharmacy;

(3) make uniliteral changes or updates to a pharmacy contract only at the time of contract renewal upon 60 days' notice to the pharmacy; provided, however, that nothing in this section shall be construed to limit the ability of a pharmacy benefit manager to make changes or updates to a formulary or to make changes or updates to rules, requirements, or compensation for any particular drug or service consistent with the health plan's direction;

(4) include a direct telephone number and email address for pharmacy inquiries in every pharmacy contract and on any website of the pharmacy benefit manager. The telephone number shall allow for the delivery of a voice message in the event a pharmacy benefit manager does not have sufficient staff to immediately answer and respond to inquiries from pharmacies. A pharmacy benefit manager shall acknowledge receipt of any inquiry within three business days of the date when the voicemail was left or email sent and provide a reasonable timeframe for when the pharmacy benefit manager will respond to any such inquiry;

(5) disclose in each pharmacy contract the sources used by the pharmacy benefit manager to calculate the drug product reimbursement paid for covered prescription drugs available under the health plan administered by the pharmacy benefit manager;

(6) accept or deny an application by a pharmacy to enroll or participate in a network maintained by a pharmacy benefit manager and notify the pharmacy of the decision in writing within 30 days from submission of a complete application. If a pharmacy benefit manager denies the application, it shall provide a specific explanation for the denial. The 30-day period shall begin from the date of postmark if the completed application for enrollment or participation is sent via postal mail or from the date of transmittal if the completed application for enrollment or participation is sent electronically or by fax;

(7) notify the pharmacy of the determination of non-renewal at least 60 days prior to the expiration of the pharmacy contract, together with a specific explanation of the reason for non-renewal, if a pharmacy benefit manager exercises a right of non-renewal of a pharmacy contract for any reason; and

(8) where it determines not to renew a pharmacy contract, or denies a pharmacy's application to participate in a pharmacy network, allow the pharmacy to reapply to be accepted into the network not later than one year from the date of the pharmacy benefit manager's determination, provided that the pharmacy provides the pharmacy benefit manager with documentation demonstrating that the reason for the original non-renewal was cured or no longer applies. Nothing in this section shall require the pharmacy benefit manager to accept such pharmacy into the network.

(c) No pharmacy benefit manager shall purchase, rent, or otherwise use any pharmacy network created by a third-party unless such third-party's pharmacy network contracts comply with this Part.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 456.2

Adopted New York State Register November 27, 2024/Volume XLVI, Issue 48, eff. 11/27/2024