Bill Text: NY A00901 | 2023-2024 | General Assembly | Introduced
Bill Title: Requires a utilization review agent to follow certain rules when establishing a step therapy protocol; requires that the protocol accepts any attestation submitted by the insured's health care professional stating that a required drug has failed as prima facie evidence that the required drug has failed.
Spectrum: Moderate Partisan Bill (Democrat 25-6)
Status: (Introduced) 2024-01-03 - referred to insurance [A00901 Detail]
Download: New_York-2023-A00901-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 901 2023-2024 Regular Sessions IN ASSEMBLY January 11, 2023 ___________ Introduced by M. of A. McDONALD, STECK -- read once and referred to the Committee on Insurance AN ACT to amend the insurance law and the public health law, in relation to requiring a utilization review agent to follow certain rules when establishing a step therapy protocol The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Subsection (a) of section 4902 of the insurance law is 2 amended by adding two new paragraphs 14 and 15 to read as follows: 3 (14) When establishing a step therapy protocol, a utilization review 4 agent shall ensure that the protocol cannot: 5 (i) require a prescription drug that has not been approved by the 6 United States Food and Drug Administration for the medical condition 7 being treated; 8 (ii) require an insured to try and fail on more than one drug before 9 providing coverage to the insured for the prescribed drug; 10 (iii) require the use of a step therapy-required drug for longer than 11 thirty days; 12 (iv) be imposed on an insured if the insured has taken the prescribed 13 drug covered by the plan within the past three hundred sixty-five days; 14 (v) require a newly enrolled insured to repeat step therapy for a 15 prescribed drug where that insured already completed step therapy for 16 that drug under a prior plan; and 17 (vi) be imposed on an insured for a prescribed drug that was previous- 18 ly approved for coverage by a plan for a specific medical condition 19 after the insured's plan implements a formulary change that impacts the 20 formulary status of the prescribed drug. 21 (15) When establishing a step therapy protocol, a utilization review 22 agent shall ensure that the protocol accepts any attestation submitted 23 by the insured's health care professional as defined in section four EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD02501-01-3A. 901 2 1 thousand nine hundred of this title stating that a required drug has 2 failed as prima facie evidence that the required drug has failed. 3 § 2. Subsections (c-3) and (g) of section 4903 of the insurance law, 4 subsection (c-3) as added and subsection (g) as amended by chapter 512 5 of the laws of 2016, are amended to read as follows: 6 (c-3) Upon a determination that the step therapy protocol should be 7 overridden, the health plan shall authorize immediate coverage for the 8 prescription drug prescribed by the insured's treating health care 9 professional. Any approval of a step therapy protocol override determi- 10 nation request shall be honored until the later of twelve months follow- 11 ing the date of the approval or renewal of the plan. 12 (g) Failure by the utilization review agent to make a determination 13 within the time periods prescribed in this section shall be deemed to be 14 an adverse determination subject to appeal pursuant to section four 15 thousand nine hundred four of this title, provided, however, that fail- 16 ure to meet such time periods for a step therapy protocol as defined in 17 subsection (g-9) of section forty-nine hundred of this title or a step 18 therapy protocol override determination pursuant to subsections (c-1), 19 (c-2) and (c-3) of this section shall be deemed to be an override of the 20 step therapy protocol. A utilization review agent's failure to comply 21 with any of the step therapy protocol requirements required in 22 subsections fourteen and fifteen of section four thousand nine hundred 23 two of this title shall be considered a basis for granting an override 24 of the step therapy protocol. 25 § 3. Section 4902 of the public health law is amended by adding two 26 new subdivisions 5 and 6 to read as follows: 27 5. When establishing a step therapy protocol, a utilization review 28 agent shall ensure that the protocol cannot: 29 (a) require a prescription drug that has not been approved by the 30 United States Food and Drug Administration for the medical condition 31 being treated; 32 (b) require an enrollee to try and fail on more than one drug before 33 providing coverage to the insured for the prescribed drug; 34 (c) require the use of a step therapy-required drug for longer than 35 thirty days; 36 (d) be imposed on an enrollee if the enrollee has taken the prescribed 37 drug covered by the plan within the past three hundred sixty-five days; 38 (f) require a newly enrolled enrollee to repeat step therapy for a 39 prescribed drug where that enrollee already completed step therapy for 40 that drug under a prior plan; and 41 (g) be imposed on an enrollee for a prescribed drug that was previous- 42 ly approved for coverage by a plan for a specific medical condition 43 after the enrollee's plan implements a formulary change that impacts the 44 formulary status of the prescribed drug. 45 6. When establishing a step therapy protocol, a utilization review 46 agent shall ensure that the protocol accepts any attestation submitted 47 by the enrollee's health care professional as defined in section forty- 48 nine hundred of this title stating that a required drug has failed as 49 prima facie evidence that the required drug has failed. 50 § 4. Subdivisions 3-c and 7 of section 4903 of the public health law, 51 subdivision 3-c as added and subdivision 7 as amended by chapter 512 of 52 the laws of 2016, are amended to read as follows: 53 3-c. Upon a determination that the step therapy protocol should be 54 overridden, the health plan shall authorize immediate coverage for the 55 prescription drug or drugs prescribed by the enrollee's treating health 56 care professional. Any approval of a step therapy protocol overrideA. 901 3 1 determination request shall be honored until the later of twelve months 2 following the date of the approval or renewal of the plan. 3 7. Failure by the utilization review agent to make a determination 4 within the time periods prescribed in this section shall be deemed to be 5 an adverse determination subject to appeal pursuant to section forty- 6 nine hundred four of this title, provided, however, that failure to meet 7 such time periods for a step therapy protocol as defined in subdivision 8 seven-f-three of section forty-nine hundred of this title or a step 9 therapy protocol override determination pursuant to subdivisions 10 three-a, three-b and three-c of this section shall be deemed to be an 11 override of the step therapy protocol. A utilization review agent's 12 failure to comply with any of the step therapy protocol requirements 13 required in subdivisions five and six of section forty-nine hundred two 14 of this title shall be considered a basis for granting an override of 15 the step therapy protocol. 16 § 5. This act shall take effect immediately.
