Bill Text: NY S04620 | 2021-2022 | General Assembly | Amended
Bill Title: Requires health plans operating in the state to furnish the cost, benefit, and coverage data as required to the enrollee, his or her health care provider, or the third-party of his or her choosing.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Passed) 2022-12-30 - APPROVAL MEMO.104 [S04620 Detail]
Download: New_York-2021-S04620-Amended.html
STATE OF NEW YORK ________________________________________________________________________ 4620--C 2021-2022 Regular Sessions IN SENATE February 8, 2021 ___________ Introduced by Sen. BRESLIN -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said committee -- recommitted to the Committee on Insurance in accordance with Senate Rule 6, sec. 8 -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said commit- tee -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said committee AN ACT to amend the insurance law, in relation to enacting the "patient Rx information and choice expansion act" The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. This act shall be known and may be cited as the "patient Rx 2 information and choice expansion act" or the "PRICE act". 3 § 2. The insurance law is amended by adding a new section 341-a to 4 read as follows: 5 § 341-a. Patient prescription pricing transparency. 1. Definitions. 6 As used in this section: 7 (a) The terms "covered individual", "health plan", and "pharmacy bene- 8 fit manager" shall have the same meanings as defined by section two 9 hundred eighty-a of the public health law. The superintendent is 10 expressly authorized to interpret these terms as if the definitions were 11 stated within this article. 12 (b) "Cost-sharing information" means the amount a covered individual 13 is required to pay to receive a drug that is covered under the covered 14 individual's health plan. 15 (c) "Covered/coverage" means those health care services to which a 16 covered individual is entitled under the terms of the health plan. 17 (d) "Interoperability element" means hardware, software, integrated 18 technologies or related licenses, technical information, privileges, 19 rights, intellectual property, upgrades, or services that may be neces- EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD08942-12-2S. 4620--C 2 1 sary to provide the data required in the requested format and consistent 2 with the required format. 3 (e) "Electronic health record" means a digital version of a patient's 4 paper chart and medical history that makes information available 5 instantly and securely to authorized users. 6 (f) "Electronic prescribing system" means a system that enables pres- 7 cribers to enter prescription information into a computer prescription 8 device and securely transmit the prescription to pharmacies using a 9 special software program and connectivity to a transmission network. 10 (g) "Electronic prescription" means an electronic prescription as 11 defined in section thirty-three hundred two of the public health law. 12 (h) "Prescriber" means a health care provider licensed to prescribe 13 medication or medical devices in the state. 14 (i) "Real-time benefit tool" or "RTBT" means an electronic 15 prescription decision support tool that: (i) is capable of integrating 16 with prescribers' electronic prescribing and, if feasible, electronic 17 health record systems; and (ii) complies with the technical standards 18 adopted by an American National Standards Institute (ANSI) accredited 19 standards development organization. 20 (j) "Authorized third-party" shall include a third-party legally 21 authorized under state or federal law subject to a Health Insurance 22 Portability and Accountability Act (HIPAA) business associate agreement. 23 2. No later than July first, two thousand twenty-three, each health 24 plan operating in the state shall, upon request of the covered individ- 25 ual, his or her health care provider, or an authorized third-party on 26 their behalf, furnish the cost, benefit, and coverage data set forth as 27 required to the covered individual, his or her health care provider, or 28 the third-party of his or her choosing and shall ensure that such data 29 is (i) current no later than one business day after any change is made; 30 (ii) provided in real time; and (iii) in a format that is easily acces- 31 sible to the covered individual, in the case of his or her health care 32 provider, through an electronic health records system. 33 3. The format of the request shall use established industry content 34 and transport standards published by: 35 (a) A standards developing organization accredited by the American 36 National Standards Institute (ANSI), including, the National Council for 37 Prescription Drug Programs (NCPDP), ASC X12, Health Level 7; or 38 (b) A relevant federal or state governing body, including the Center 39 for Medicare & Medicaid Services or the Office of the National Coordina- 40 tor for Health Information Technology; or 41 (c) Another format deemed acceptable to the department which provides 42 the data prescribed in subdivision two of this section and in the same 43 timeliness as required by this section. 44 4. A facsimile shall not be considered an acceptable electronic format 45 pursuant to this section. 46 5. Upon such request, the following data shall be provided for any 47 drug covered under the covered individual's health plan: 48 (a) patient-specific eligibility information; 49 (b) patient-specific prescription cost and benefit data, such as 50 applicable formulary, benefit, coverage and cost-sharing data for the 51 prescribed drug and clinically-appropriate alternatives, when appropri- 52 ate; 53 (c) patient-specific cost-sharing information that describes variance 54 in cost-sharing based on the pharmacy dispensing the prescribed drug or 55 its alternatives, and in relation to the patient's benefit (i.e., spend 56 related to out-of-pocket maximum);S. 4620--C 3 1 (d) information regarding lower cost clinically-appropriate treatment 2 alternatives; and 3 (e) applicable utilization management requirements. 4 6. Any health plan or pharmacy benefit manager shall furnish the data 5 as required whether the request is made using the drug's unique billing 6 code, such as a National Drug Code or Healthcare Common Procedure Coding 7 System code or descriptive term. A health plan or pharmacy benefit 8 manager shall not deny or unreasonably delay a request as a method of 9 blocking the data set forth as required from being shared based on how 10 the drug was requested. 11 7. A health plan or pharmacy benefit manager shall not restrict, 12 prohibit, or otherwise hinder the prescriber from communicating or 13 sharing benefit and coverage information that reflects other choices, 14 such as cash price, lower cost clinically-appropriate alternatives, 15 whether or not they are covered under the covered individual's plan, 16 patient assistance and support programs and the cost available at the 17 patient's pharmacy of choice. 18 8. A health plan or pharmacy benefit manager shall not, except as may 19 be required by law, interfere with, prevent, or materially discourage 20 access, exchange, or use of the data as required, which may include 21 charging fees, or not responding to a request for such data in a reason- 22 able time frame; nor penalize a health care provider or professional for 23 disclosing such information to a covered individual or legally prescrib- 24 ing, administering, or ordering a clinically appropriate or lower-cost 25 alternative. 26 9. Nothing in this section shall be construed to limit access to the 27 most up-to-date patient-specific eligibility or patient-specific 28 prescription cost and benefit data by the health plan. 29 10. Nothing in this section shall interfere with patient choice and a 30 health care professional's ability to convey the full range of 31 prescription drug cost options to a patient. Health plans or pharmacy 32 benefit managers shall not restrict a health care professional from 33 communicating to the patient prescription cost options. 34 11. No RTBT shall require a patient to utilize specific plan preferred 35 drugs or pharmacies. 36 § 3. Severability. If any provision of this act, or any application 37 of any provision of this act, is held to be invalid, or to violate or 38 be inconsistent with any federal law or regulation, that shall not 39 affect the validity or effectiveness of any other provision of this 40 act, or of any other application of any provision of this act, which 41 can be given effect without that provision or application; and to that 42 end, the provisions and applications of this act are severable. 43 § 4. This act shall take effect one hundred eighty days after it shall 44 have become a law. Effective immediately, the addition, amendment and/or 45 repeal of any rule or regulation necessary for the implementation of 46 this act on its effective date are authorized to be made and completed 47 on or before such effective date.
