Bill Text: NY S06020 | 2021-2022 | General Assembly | Introduced
Bill Title: Amends provisions governing reimbursement practices of pharmacy benefit managers to ensure that pharmacies are not reimbursed an amount less than the cost of procuring the drugs.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2022-01-05 - REFERRED TO HEALTH [S06020 Detail]
Download: New_York-2021-S06020-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 6020 2021-2022 Regular Sessions IN SENATE March 29, 2021 ___________ Introduced by Sen. THOMAS -- read twice and ordered printed, and when printed to be committed to the Committee on Health AN ACT to amend the public health law, in relation to pharmacy benefit managers The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Section 280-a of the public health law, as added by chapter 2 540 of the laws of 2015, subdivisions 3 and 4 as added by section 2 of 3 part MM of chapter 57 of the laws of 2018, is amended to read as 4 follows: 5 § 280-a. Pharmacy benefit managers. 1. Definitions. As used in this 6 section, the following terms shall have the following meanings: 7 (a) "Pharmacy benefit manager" means an entity that contracts with 8 pharmacies or pharmacy contracting agents on behalf of a health plan, 9 state agency, insurer, managed care organization, or other third party 10 payor to provide pharmacy health benefit services or administration. 11 (b) "Maximum allowable cost price" means a maximum reimbursement 12 amount set by the pharmacy benefit manager for therapeutically equiv- 13 alent multiple source generic drugs. 14 (c) "Pharmacy acquisition cost" means the amount that a pharmaceutical 15 wholesaler charges for a pharmaceutical product as listed on the pharma- 16 cy's billing invoice. 17 (d) "Pharmacy benefit manager affiliate" means a pharmacy or pharma- 18 cist that directly or indirectly, through one or more intermediaries 19 owns or controls, is owned or controlled by, or is under common owner- 20 ship or control with a pharmacy benefit manager. 21 (e) "Pharmacy benefits plan or program" means a plan or program that 22 pays for, reimburses, covers the cost of, or otherwise provides for 23 pharmacist services to individuals who reside in or are employed in this 24 state. EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD10670-02-1S. 6020 2 1 2. A pharmacy benefit manager shall, with respect to contracts between 2 a pharmacy benefit manager and a pharmacy or, alternatively, a pharmacy 3 benefit manager and a pharmacy's contracting agent, such as a pharmacy 4 services administrative organization, include a reasonable process to 5 appeal, investigate and resolve disputes regarding multi-source generic 6 drug pricing, including being below the pharmacy acquisition cost. The 7 appeals process shall include the following provisions: 8 (a) the right to appeal by the pharmacy and/or the pharmacy's 9 contracting agent shall be limited to thirty days following the initial 10 claim submitted for payment; 11 (b) a telephone number through which a network pharmacy may contact 12 the pharmacy benefit manager for the purpose of filing an appeal and an 13 electronic mail address of the individual who is responsible for proc- 14 essing appeals; 15 (c) the pharmacy benefit manager shall send an electronic mail message 16 acknowledging receipt of the appeal. The pharmacy benefit manager shall 17 respond in an electronic message to the pharmacy and/or the pharmacy's 18 contracting agent filing the appeal within seven business days indicat- 19 ing its determination. If the appeal is determined to be valid, the 20 maximum allowable cost for the drug shall be adjusted for the appealing 21 pharmacy effective as of the date of the original claim for payment. The 22 pharmacy benefit manager shall require the appealing pharmacy to reverse 23 and rebill the claim in question in order to obtain the corrected 24 reimbursement; 25 (d) if an update to the maximum allowable cost is warranted, the phar- 26 macy benefit manager or covered entity shall adjust the maximum allow- 27 able cost of the drug effective for all [similarly situated] pharmacies 28 in its network in the state on the date the appeal was determined to be 29 valid; and 30 (e) if an appeal is denied, the pharmacy benefit manager shall identi- 31 fy the national drug code of a therapeutically equivalent drug, as 32 determined by the federal Food and Drug Administration, that is avail- 33 able for purchase by pharmacies in this state from wholesalers regis- 34 tered pursuant to subdivision four of section sixty-eight hundred eight 35 of the education law at a price which is equal to or less than the maxi- 36 mum allowable cost for that drug as determined by the pharmacy benefit 37 manager. 38 2-a. (a) If the national drug code number provided by the pharmacy 39 benefit manager is not available below the pharmacy acquisition cost 40 from the pharmaceutical wholesaler from whom the pharmacy or pharmacist 41 purchases the majority of prescription drugs for resale, then the phar- 42 macy benefit manager shall adjust the maximum allowable cost above the 43 challenging pharmacy's pharmacy acquisition cost and permit the pharmacy 44 to reverse and rebill each claim affected by the inability to procure 45 the drug at a cost that is equal to or less than the previously chal- 46 lenged maximum allowable cost. 47 (b) A pharmacy benefit manager shall not reimburse a pharmacy or phar- 48 macist in this state an amount less than the amount that the pharmacy 49 benefit manager reimburses a pharmacy benefit manager affiliate for 50 providing the same pharmacist services. 51 (c) The amount shall be calculated on a per unit basis based on the 52 same generic product identified or generic code number. 53 (d) A pharmacy or pharmacist may decline to provide the pharmacist 54 services to a patient or pharmacy benefit manager if, as a result of a 55 maximum allowable cost, a pharmacy or pharmacist is to be paid less thanS. 6020 3 1 the pharmacy acquisition cost of the pharmacy providing pharmacist 2 services. 3 3. No pharmacy benefit manager shall, with respect to contracts 4 between such pharmacy benefit manager and a pharmacy or, alternatively, 5 such pharmacy benefit manager and a pharmacy's contracting agent, such 6 as a pharmacy services administrative organization: 7 (a) prohibit or penalize a pharmacist or pharmacy from disclosing to 8 an individual purchasing a prescription medication information regard- 9 ing: 10 (1) the cost of the prescription medication to the individual, or 11 (2) the availability of any therapeutically equivalent alternative 12 medications or alternative methods of purchasing the prescription medi- 13 cation, including but not limited to, paying a cash price; or 14 (b) charge or collect from an individual a copayment that exceeds the 15 total submitted charges by the pharmacy for which the pharmacy is paid. 16 If an individual pays a copayment, the pharmacy shall retain the adjudi- 17 cated costs and the pharmacy benefit manager shall not redact or recoup 18 the adjudicated cost. 19 4. A pharmacy benefit manager shall: 20 (a) provide access to its maximum allowable cost prices to each phar- 21 macy subject to the maximum allowable cost price; and 22 (b) update its maximum allowable cost prices on a timely basis, but in 23 no event longer than seven calendar days from an increase of ten percent 24 or more in the pharmacy acquisition cost from sixty percent or more of 25 the pharmaceutical wholesaler doing business in the state or a change in 26 the methodology on which the maximum allowable cost price is based or in 27 the value of a variable involved in the methodology. 28 5. Any provision of a contract that violates the provisions of this 29 section shall be deemed to be void and unenforceable. 30 § 2. This act shall take effect immediately.
