N.Y. Comp. Codes R. & Regs. tit. 11 § 458.3

Current through Register Vol. 46, No. 50, December 11, 2024

Section 458.3 - Consumer resources

(a) Formulary Directories. This subdivision shall apply to all pharmacy benefit managers providing clinical or other formulary or preferred drug list development or management on behalf of health plans. Pharmacy benefit managers shall come into compliance with the provisions of this subdivision by July 1, 2025.

(1) A pharmacy benefit manager shall publish on its website, in a manner that is easily accessible to covered individuals and prospective covered individuals, an up-to-date, accurate, and complete list of all covered prescription drugs on each health plan's formulary drug list, including any tiering structure that it has adopted and any restrictions on the manner in which a prescription drug may be obtained. The formulary drug list shall clearly identify the prescription drugs that are available without annual deductibles, co-payments, or coinsurance.

(2) If a covered individual reasonably relied on information on a pharmacy benefit manager's listing on its website as required by paragraph (1) of this subdivision in obtaining a prescription drug from a pharmacy, the pharmacy benefit manager shall:

(i) not impose a cost-sharing amount for such prescription drug that is greater than the cost-sharing amount that was listed on the website;

(ii) apply the deductible or out-of-pocket maximum, if any, that would apply based upon the website information on which the covered individual reasonably relied; and

(iii) not pass on to the health plan or pharmacies any cost associated with compliance with this paragraph.

(b) Network Pharmacy Directories. This subdivision applies to pharmacy benefit managers that perform retail network management or contract with network pharmacies on behalf of a health plan. Pharmacy benefit managers shall come into compliance with the provisions of this subdivision by July 1, 2025.

(1) A pharmacy benefit manager shall publish on its website, in a manner that is easily accessible to covered individuals and prospective covered individuals, a list for each health plan for which the pharmacy benefit manager performs pharmacy benefit management services that identifies each pharmacy within each network. The website shall also contain pharmacy directory information with respect to each pharmacy listed, including the pharmacy's name, address, telephone number, and, if available, email address.

(2) A pharmacy benefit manager shall update the pharmacy directory information on its website for each health plan within five business days of the addition or termination of a pharmacy from a health plan's network.

(3) If a covered individual reasonably relied on information contained on a listing on a pharmacy benefit manager's website as required by paragraph (1) of this subdivision in selecting a pharmacy at which to receive prescription drug services, the pharmacy benefit manager shall:

(i) not impose a cost-sharing amount for such covered prescription drug that is greater than the costsharing amount that would apply to the covered individual had such covered prescription drug been furnished by an in-network pharmacy;

(ii) apply the deductible or out-of-pocket maximum, if any, that would apply if such prescription drug were furnished by an in-network pharmacy; and

(iii) shall not pass on to the health plan or pharmacies any cost associated with compliance with this paragraph.

(c) Inquiries by Covered Individuals. A pharmacy benefit manager shall have a direct telephone number and email address listed on its website for inquiries by covered individuals. A pharmacy benefit manager shall have sufficient staff to answer and respond to inquiries from covered individuals in a reasonable amount of time.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 458.3

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