Relates to coverage for single source drugs

Summary of provisions

Section 1 of the bill amends the adds a new paragraph 29 to subsection (l) of § 3216 of the insurance law to require continued coverage of a prescription drug if such drug was previously covered under an individual's insurance plan and no generic equivalent is available.

Section 2 of the bill adds a new paragraph 18 to subsection (k) of § 3221 of the insurance law requiring each group policy to continue coverage of a prescription drug during a grievance or an appeal when a policy removes a prescription from the formulary while patient was taking such drug as part of a prescribed therapy.

Section 3 of the bill adds a new subsection bb to § 4303 of the insurance law requiring contracts issued by a health service corporation or a medical expense indemnity corporation to continue coverage of a prescription drug during a grievance or an appeal when a policy removes a prescription from the formulary while the patient was taking such drug as part of a prescribed therapy.

Section 4 sets forth an effective date of the first day of the calendar month next succeeding the sixtieth day after it shall have become a law but shall apply only to policies and contracts issued, renewed or amended on or after the effective date of this act.

Justification

This legislation was modeled after a 1998 law in California. This bill would require an insurance plan to continue their coverage of prescription medication for patients currently taking the medication when no generic equivalent is available.

When a patient is on a prescribed therapy it is very important for the patient to maintain that therapy to the end. When a drug is dropped from a plan, the consequences can be dire and/or costly for the patients that are in various stages of therapy with that drug. If the patient were to maintain the prescribed therapy, the out of pocket cost to the patient could be so exorbitant that the patient would eventually stop taking the prescription prior to the completion of the therapy.

In another circumstance, the patient may be forced to change to a similar brand name drug - that is covered under the plan- in the midst of the prescribed therapy. That new drug may not be as suitable or may cause adverse reactions. The new drug may not react well with

other medication that the patient is taking. Also, the new drug may not achieve the desired effect that the other drug accomplished.

The physician should have the final say in which prescription a patient takes. Although one drug may seem to have the same effect as another, it may not be as compatible with other medications a patient is taking or, one drug may be more effective under certain conditions. In any event, health care cannot be directed by the bottom dollar in every instance. When a patient's well being is affected, policy must be changed for the betterment of the patient.

Legislative history

Senate: New Bill Assembly: A.9448 of 1999/2000, A.1912 of 2001/2002 A.4191 of 2009/2010

Fiscal implications

None.

Effective date

This act shall take effect on the first day of the calendar month next succeeding the sixtieth day after it shall have become a law but shall apply only to policies and contracts issued, renewed or amended on or after the effective date of this act.