S T A T E O F N E W Y O R K
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5411--C
Cal. No. 594
2021-2022 Regular Sessions
I N A S S E M B L Y
February 16, 2021
___________
Introduced by M. of A. McDONALD, THIELE, ENGLEBRIGHT, BURDICK, MONTESA-
NO, SCHMITT, REILLY, LAWLER, McDONOUGH, LEMONDES, DICKENS, SILLITTI,
CUSICK, SIMON, ANGELINO, SALKA, DURSO, JACKSON, GUNTHER, GOTTFRIED,
STECK, HAWLEY, FORREST -- read once and referred 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 Assembly Rule 3, sec. 2 --
committee discharged, bill amended, ordered reprinted as amended and
recommitted to said committee -- reported from committee, advanced to
a third reading, amended and ordered reprinted, retaining its place on
the order of third reading
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:
Section 1. This act shall be known and may be cited as the "patient Rx
information and choice expansion act" or the "PRICE act".
§ 2. The insurance law is amended by adding a new section 341-a to
read as follows:
§ 341-A. PATIENT PRESCRIPTION PRICING TRANSPARENCY. 1. DEFINITIONS.
AS USED IN THIS SECTION:
(A) "HEALTH PLAN" MEANS BENEFITS PROVIDED BY ANY ENTITY DELIVERING OR
ISSUING FOR DELIVERY A POLICY OF ACCIDENT AND HEALTH INSURANCE PURSUANT
TO SECTION THREE THOUSAND TWO HUNDRED SIXTEEN, OR A GROUP OR BLANKET
ACCIDENT AND HEALTH INSURANCE POLICY PURSUANT TO SECTION THREE THOUSAND
TWO HUNDRED TWENTY-ONE, OR PROVIDING BENEFITS PURSUANT TO SECTION FOUR
THOUSAND THREE HUNDRED THREE OF THIS CHAPTER.
(B) "COST-SHARING INFORMATION" MEANS THE AMOUNT AN ENROLLEE IS
REQUIRED TO PAY IN ORDER TO RECEIVE A DRUG THAT IS COVERED UNDER THE
ENROLLEE'S HEALTH PLAN.
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD08942-06-2
A. 5411--C 2
(C) "COVERED/COVERAGE" MEANS THOSE HEALTH CARE SERVICES TO WHICH AN
ENROLLEE IS ENTITLED UNDER THE TERMS OF THE HEALTH PLAN.
(D) "ENROLLEE" MEANS THE COVERED INDIVIDUAL, POLICYHOLDER, SUBSCRIBER,
THE INSURED, OR PERSON WHO HAS AUTHORITY UNDER APPLICABLE LAW TO ACT ON
BEHALF OF AN ENROLLEE IN MAKING DECISIONS RELATED TO HEALTH CARE, A
HEALTH PLAN, OR PHARMACY BENEFIT MANAGER, OR ITS AFFILIATES OR ENTITIES.
(E) "INTEROPERABILITY ELEMENT" MEANS HARDWARE, SOFTWARE, INTEGRATED
TECHNOLOGIES OR RELATED LICENSES, TECHNICAL INFORMATION, PRIVILEGES,
RIGHTS, INTELLECTUAL PROPERTY, UPGRADES, OR SERVICES THAT MAY BE NECES-
SARY TO PROVIDE THE DATA REQUIRED IN THE REQUESTED FORMAT AND CONSISTENT
WITH THE REQUIRED FORMAT.
(F) "PHARMACY BENEFIT MANAGER (PBM)" ENSURE THAT THIS TERM INCLUDES
PHARMACY BENEFIT MANAGERS, AFFILIATES, OR OTHER ENTITIES ACTING ON THEIR
BEHALF.
(G) "ELECTRONIC HEALTH RECORD" MEANS A DIGITAL VERSION OF A PATIENT'S
PAPER CHART AND MEDICAL HISTORY THAT MAKES INFORMATION AVAILABLE
INSTANTLY AND SECURELY TO AUTHORIZED USERS.
(H) "ELECTRONIC PRESCRIBING SYSTEM" MEANS A SYSTEM THAT ENABLES PRES-
CRIBERS TO ENTER PRESCRIPTION INFORMATION INTO A COMPUTER PRESCRIPTION
DEVICE AND SECURELY TRANSMIT THE PRESCRIPTION TO PHARMACIES USING A
SPECIAL SOFTWARE PROGRAM AND CONNECTIVITY TO A TRANSMISSION NETWORK.
(I) "ELECTRONIC PRESCRIPTION" MEANS AN ELECTRONIC PRESCRIPTION AS
DEFINED IN SECTION THIRTY-THREE HUNDRED TWO OF THE PUBLIC HEALTH LAW.
(J) "PRESCRIBER" MEANS A HEALTH CARE PROVIDER LICENSED TO PRESCRIBE
MEDICATION OR MEDICAL DEVICES IN THE STATE.
(K) "REAL-TIME BENEFIT TOOL" OR "RTBT" MEANS AN ELECTRONIC
PRESCRIPTION DECISION SUPPORT TOOL THAT: (I) IS CAPABLE OF INTEGRATING
WITH PRESCRIBERS' ELECTRONIC PRESCRIBING AND ELECTRONIC HEALTH RECORD
SYSTEMS; AND (II) COMPLIES WITH THE TECHNICAL STANDARDS ADOPTED BY AN
AMERICAN NATIONAL STANDARDS INSTITUTE (ANSI) ACCREDITED STANDARDS DEVEL-
OPMENT ORGANIZATION.
2. NO LATER THAN JULY FIRST, TWO THOUSAND TWENTY-THREE, EACH HEALTH
PLAN OPERATING IN THE STATE SHALL, UPON REQUEST OF THE ENROLLEE, HIS OR
HER HEALTH CARE PROVIDER, OR A THIRD-PARTY ON THEIR BEHALF, FURNISH THE
COST, BENEFIT, AND COVERAGE DATA SET FORTH AS REQUIRED TO THE ENROLLEE,
HIS OR HER HEALTH CARE PROVIDER, OR THE THIRD-PARTY OF HIS OR HER CHOOS-
ING AND SHALL ENSURE THAT SUCH DATA IS (I) CURRENT NO LATER THAN ONE
BUSINESS DAY AFTER ANY CHANGE IS MADE; (II) PROVIDED IN REAL TIME; AND
(III) IN THE SAME FORMAT THAT THE REQUEST IS MADE BY THE ENROLLEE OR HIS
OR HER HEALTH CARE PROVIDER.
3. THE FORMAT OF THE REQUEST SHALL USE ESTABLISHED INDUSTRY CONTENT
AND TRANSPORT STANDARDS PUBLISHED BY:
(A) A STANDARDS DEVELOPING ORGANIZATION ACCREDITED BY THE AMERICAN
NATIONAL STANDARDS INSTITUTE (ANSI), INCLUDING, THE NATIONAL COUNCIL FOR
PRESCRIPTION DRUG PROGRAMS (NCPDP), ASC X12, HEALTH LEVEL 7; OR
(B) A RELEVANT FEDERAL OR STATE GOVERNING BODY, INCLUDING THE CENTER
FOR MEDICARE & MEDICAID SERVICES OR THE OFFICE OF THE NATIONAL COORDINA-
TOR FOR HEALTH INFORMATION TECHNOLOGY.
4. A FACSIMILE, PROPRIETARY PAYOR OR PATIENT PORTAL, OR OTHER ELEC-
TRONIC FORM SHALL NOT BE CONSIDERED ACCEPTABLE ELECTRONIC FORMATS PURSU-
ANT TO THIS SECTION.
5. UPON SUCH REQUEST, THE FOLLOWING DATA SHALL BE PROVIDED FOR ANY
DRUG COVERED UNDER THE ENROLLEE'S HEALTH PLAN:
(A) PATIENT-SPECIFIC ELIGIBILITY INFORMATION;
(B) PATIENT-SPECIFIC PRESCRIPTION COST AND BENEFIT DATA, SUCH AS
APPLICABLE FORMULARY, BENEFIT, COVERAGE AND COST-SHARING DATA FOR THE
A. 5411--C 3
PRESCRIBED DRUG AND CLINICALLY-APPROPRIATE ALTERNATIVES, WHEN APPROPRI-
ATE;
(C) PATIENT-SPECIFIC COST-SHARING INFORMATION THAT DESCRIBES VARIANCE
IN COST-SHARING BASED ON THE PHARMACY DISPENSING THE PRESCRIBED DRUG OR
ITS ALTERNATIVES, AND IN RELATION TO THE PATIENT'S BENEFIT (I.E., SPEND
RELATED TO OUT-OF-POCKET MAXIMUM);
(D) INFORMATION REGARDING LOWER COST CLINICALLY-APPROPRIATE TREATMENT
ALTERNATIVES; AND
(E) APPLICABLE UTILIZATION MANAGEMENT REQUIREMENTS.
6. ANY HEALTH PLAN OR PBM SHALL FURNISH THE DATA AS REQUIRED WHETHER
THE REQUEST IS MADE USING THE DRUG'S UNIQUE BILLING CODE, SUCH AS A
NATIONAL DRUG CODE OR HEALTHCARE COMMON PROCEDURE CODING SYSTEM CODE OR
DESCRIPTIVE TERM. A HEALTH PLAN OR PBM SHALL NOT DENY OR DELAY A REQUEST
AS A METHOD OF BLOCKING THE DATA SET FORTH AS REQUIRED FROM BEING SHARED
BASED ON HOW THE DRUG WAS REQUESTED.
7. A HEALTH PLAN, OR ENTITIES ACTING ON A HEALTH PLAN'S BEHALF, SHALL
NOT RESTRICT, PROHIBIT, OR OTHERWISE HINDER THE PRESCRIBER FROM COMMU-
NICATING OR SHARING BENEFIT AND COVERAGE INFORMATION THAT REFLECTS OTHER
CHOICES, SUCH AS CASH PRICE, LOWER COST CLINICALLY-APPROPRIATE ALTERNA-
TIVES, WHETHER OR NOT THEY ARE COVERED UNDER THE ENROLLEE'S PLAN,
PATIENT ASSISTANCE AND SUPPORT PROGRAMS AND THE COST AVAILABLE AT THE
PATIENT'S PHARMACY OF CHOICE.
8. A HEALTH PLAN, OR ENTITIES ACTING ON A HEALTH PLAN'S BEHALF, SHALL
NOT, EXCEPT AS MAY BE REQUIRED BY LAW, INTERFERE WITH, PREVENT, OR MATE-
RIALLY DISCOURAGE ACCESS, EXCHANGE, OR USE OF THE DATA AS REQUIRED,
WHICH MAY INCLUDE CHARGING FEES, NOT RESPONDING TO A REQUEST AT THE TIME
MADE WHERE SUCH A RESPONSE IS REASONABLY POSSIBLE, IMPLEMENTING TECHNOL-
OGY IN NONSTANDARD WAYS OR INSTITUTING ENROLLEE CONSENT REQUIREMENTS,
PROCESSES, POLICIES, PROCEDURES, OR RENEWALS THAT ARE LIKELY TO SUBSTAN-
TIALLY INCREASE THE COMPLEXITY OR BURDEN OF ACCESSING, EXCHANGING, OR
USING SUCH DATA; NOR PENALIZE A HEALTH CARE PROVIDER OR PROFESSIONAL FOR
DISCLOSING SUCH INFORMATION TO AN ENROLLEE OR PRESCRIBING, ADMINISTER-
ING, OR ORDERING A CLINICALLY APPROPRIATE OR LOWER-COST ALTERNATIVE.
9. NOTHING IN THIS SECTION SHALL BE CONSTRUED TO LIMIT ACCESS TO THE
MOST UP-TO-DATE PATIENT-SPECIFIC ELIGIBILITY OR PATIENT-SPECIFIC
PRESCRIPTION COST AND BENEFIT DATA BY THE HEALTH PLAN.
10. NOTHING IN THIS SECTION SHALL INTERFERE WITH PATIENT CHOICE AND A
HEALTH CARE PROFESSIONAL'S ABILITY TO CONVEY THE FULL RANGE OF
PRESCRIPTION DRUG COST OPTIONS TO A PATIENT. HEALTH PLANS, OR ENTITIES
ACTING ON THEIR BEHALF, SHALL NOT RESTRICT A HEALTH CARE PROFESSIONAL
FROM COMMUNICATING TO THE PATIENT PRESCRIPTION COST OPTIONS.
11. NO RTBT SHALL REQUIRE OR INFLUENCE A PATIENT TO UTILIZE SPECIFIC
PLAN PREFERRED DRUGS OR PHARMACIES.
§ 3. Severability. If any provision of this act, or any application
of any provision of this act, is held to be invalid, or to violate or
be inconsistent with any federal law or regulation, that shall not
affect the validity or effectiveness of any other provision of this
act, or of any other application of any provision of this act, which
can be given effect without that provision or application; and to that
end, the provisions and applications of this act are severable.
§ 4. This act shall take effect July 1, 2023. Effective immediately,
the addition, amendment and/or repeal of any rule or regulation neces-
sary for the implementation of this act on its effective date are
authorized to be made and completed on or before such effective date.