Let Doctors Dispense Key Meds

Section 1. Subsection (i) of section 3216 of the insurance law is amended by adding two new paragraphs 28-a and 28-b to read as follows:

(28-a) (A) Any policy that provides coverage for prescription drugs and also provides coverage for cancer chemotherapy treatment shall permit each insured to fill any covered prescription under paragraph twelve-a of this subsection that may be obtained at a network participating mail order or other non-retail pharmacy, at the insured's option, from a network participating oncologist providing services in accordance with section sixty-eight hundred seven of the education law. Any policy providing such coverage shall not impose a co-payment fee or other condition on any insured who elects to purchase oral anticancer medications from a prescribing network participating oncologist which is not also imposed on insureds electing to purchase drugs from a network participating mail order or other non-retail pharmacy. The policy shall not exclude from network participation any oncologist dispensing or involved in the provision of pharmacy services in accordance with section sixty-eight hundred seven of the education law due to their dispensing or the provision of said pharmacy services. This paragraph shall also apply to any pharmacy benefits manager as defined in section two hundred eighty-a of the public health law.

(B) For the purposes of this paragraph, "oncologist" shall mean a licensed or registered physician who is board certified or board eligible in medical oncology, radiation oncology, hematology, or another oncology specialty recognized by the American board of medical special-

EXPLANATION--Matter in italics (underscored) is new; matter in brackets

[ ] is old law to be omitted.

LBD10670-01-7

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ties, or a surgeon who consults predominantly with patients who have a cancer diagnosis.

(28-b) (A) Any policy that provides coverage for prescription drugs and also provides coverage for human immunodeficiency virus infection and acquired immune deficiency syndrome treatment shall permit each insured to fill any covered prescription that may be obtained at a network participating mail order or other non-retail pharmacy, at the insured's option, from a network participating physician providing services in accordance with section sixty-eight hundred seven of the education law. Any policy providing such coverage shall not impose a co-payment fee or other condition on any insured who elects to purchase antiretroviral medications from a prescribing network participating physician which is not also imposed on insureds electing to purchase drugs from a network participating mail order or other non-retail pharmacy. The policy shall not exclude from network participation any physician dispensing or involved in the provision of pharmacy services in accordance with section sixty-eight hundred seven of the education law due to their dispensing or the provision of said pharmacy services. This paragraph shall also apply to any pharmacy benefits manager as defined in section two hundred eighty-a of the public health law.

(B) For the purposes of this paragraph, "antiretroviral medication" shall mean a drug used in the treatment of human immunodeficiency virus infection and acquired immune deficiency syndrome.

§ 2. Subsection (l) of section 3221 of the insurance law is amended by adding two new paragraphs 18-a and 18-b to read as follows:

(18-a) (A) Any policy that provides coverage for prescription drugs and also provides coverage for cancer chemotherapy treatment shall permit each insured to fill any covered prescription under paragraph twelve-a of this subsection that may be obtained at a network participating mail order or other non-retail pharmacy, at the insured's option, from a network participating oncologist providing services in accordance with section sixty-eight hundred seven of the education law. Any policy providing such coverage shall not impose a co-payment fee or other condition on any insured who elects to purchase oral anticancer medications from a prescribing network participating oncologist which is not also imposed on insureds electing to purchase drugs from a network participating mail order or other non-retail pharmacy. The policy shall not exclude from network participation any oncologist dispensing or involved in the provision of pharmacy services in accordance with section sixty-eight hundred seven of the education law due to their dispensing or the provision of said pharmacy services. This paragraph shall also apply to any pharmacy benefits manager as defined in section two hundred eighty-a of the public health law.

(B) For the purposes of this paragraph, "oncologist" shall mean a licensed or registered physician who is board certified or board eligible in medical oncology, radiation oncology, hematology, or another oncology specialty recognized by the American board of medical specialties, or a surgeon who consults predominantly with patients who have a cancer diagnosis.

(18-b) (A) Any policy that provides coverage for prescription drugs and also provides coverage for human immunodeficiency virus infection and acquired immune deficiency syndrome treatment shall permit each insured to fill any covered prescription that may be obtained at a network participating mail order or other non-retail pharmacy, at the insured's option, from a network participating physician providing services in accordance with section sixty-eight hundred seven of the

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education law. Any policy providing such coverage shall not impose a co-payment fee or other condition on any insured who elects to purchase antiretroviral medications from a prescribing network participating physician which is not also imposed on insureds electing to purchase drugs from a network participating mail order or other non-retail pharmacy. The policy or a pharmacy benefit manager, as defined in section two hundred eighty-a of the public health law, shall not exclude from network participation any physician dispensing or involved in the provision of pharmacy services in accordance with section sixty-eight hundred seven of the education law due to their dispensing or the provision of said pharmacy services. This paragraph shall also apply to any pharmacy benefits manager as defined in section two hundred eighty-a of the public health law.

(B) For the purposes of this paragraph, "antiretroviral medication" shall mean a drug used in the treatment of human immunodeficiency virus infection and acquired immune deficiency syndrome.

§ 3. Section 4303 of the insurance law is amended by adding two new subsections (kk-1) and (kk-2) to read as follows:

(kk-1) (A) Any contract that provides coverage for prescription drugs and also provides coverage for cancer chemotherapy treatment shall permit each insured to fill any covered prescription under subsection (q-1) of this section that may be obtained at a network participating mail order or other non-retail pharmacy, at the insured's option, from a network participating oncologist providing services in accordance with section sixty-eight hundred seven of the education law. Any policy providing such coverage shall not impose a co-payment fee or other condition on any insured who elects to purchase oral anticancer medications from a prescribing network participating oncologist which is not also imposed on insureds electing to purchase drugs from a network participating mail order or other non-retail pharmacy. The policy shall not exclude from network participation any oncologist dispensing or involved in the provision of pharmacy services in accordance with section sixty-eight hundred seven of the education law due to their dispensing or the provision of said pharmacy services. This paragraph shall also apply to any pharmacy benefits manager as defined in section two hundred eighty-a of the public health law.

(B) For the purposes of this paragraph, "oncologist" shall mean a licensed or registered physician who is board certified or board eligible in medical oncology, radiation oncology, hematology, or another oncology specialty recognized by the American board of medical specialties, or a surgeon who consults predominantly with patients who have a cancer diagnosis.

(kk-2) (A) Any contract that provides coverage for prescription drugs and also provides coverage for human immunodeficiency virus infection and acquired immune deficiency syndrome treatment shall permit each insured to fill any covered prescription that may be obtained at a network participating mail order or other non-retail pharmacy, at the insured's option, from a network participating physician providing services in accordance with section sixty-eight hundred seven of the education law. Any contract providing such coverage shall not impose a co-payment fee or other condition on any insured who elects to purchase antiretroviral medications from a prescribing network participating physician which is not also imposed on insureds electing to purchase drugs from a network participating mail order or other non-retail pharmacy. The contract or a pharmacy benefit manager, as defined in section two hundred eighty-a of the public health law, shall not exclude from

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network participation any physician dispensing or involved in the provision of pharmacy services in accordance with section sixty-eight hundred seven of the education law due to their dispensing or the provision of said pharmacy services. This paragraph shall also apply to any pharmacy benefits manager as defined in section two hundred eighty-a of the public health law.

(B) For the purposes of this paragraph, "antiretroviral medication" shall mean a drug used in the treatment of human immunodeficiency virus infection and acquired immune deficiency syndrome.

§ 4. Subdivisions 11, 12, 13, 14, 15, 16, and 17 of section 238 of the public health law are renumbered subdivisions 13, 14, 15, 16, 17, 18, and 19 and two new subdivisions 11 and 12 are added to read as follows:

11. "Oncologist" shall mean a licensed or registered physician who is board certified or board eligible in medical oncology, radiation oncology, hematology, or another oncology specialty recognized by the American board of medical specialties, or a surgeon who consults predominantly with patients who have a cancer diagnosis.

12. "Oncology group practice" shall mean a group practice in which each practitioner who is a member of the group is an oncologist.

§ 5. Subdivision 4 of section 238-a of the public health law, as added by chapter 803 of the laws of 1992, paragraphs (a), (b), and (c) as amended by chapter 591 of the laws of 2000, and paragraph (d) as amended by chapter 443 of the laws of 1993, is amended to read as follows:

4. An ownership interest or an investment interest shall not be subject to subdivision one of this section if:

(a) the health care provider authorized to provide clinical laboratory services, pharmacy services, radiation therapy services, physical therapy services or x-ray or imaging services is in a rural area and the referring practitioner or the patient is in such rural area; or

(b) the clinical laboratory services, pharmacy services, radiation therapy services, physical therapy services or x-ray or imaging services are provided by a general hospital, the referring practitioner is authorized to perform services at such general hospital and the ownership or investment interest is in the general hospital itself and not merely in a subdivision thereof; or

(c) the clinical laboratory services, pharmacy services, radiation therapy services, physical therapy services or x-ray or imaging services are provided by an ambulatory surgical center issued an operating certificate pursuant to article twenty-eight of this chapter in conjunction with a surgical procedure performed by the referring practitioner at the ambulatory surgical center; or

(d) the pharmacy services are provided to a cancer patient of an oncology group practice by a pharmacy licensed under subdivision two of section sixty-eight hundred eight of the education law, the ownership or investment interest of which is held exclusively by practitioners of the oncology group practice, of which the prescribing practitioner is a member; or

(e) the pharmacy services are provided to a human immunodeficiency virus infection or acquired immune deficiency syndrome patient of a group practice by a pharmacy licensed under subdivision two of section sixty-eight hundred eight of the education law, the ownership or investment interest of which is held exclusively by practitioners of the group practice, of which the prescribing practitioner is a member;

[(d)] (f) and if each practitioner who is an interested investor in a health care provider within a category specified in paragraph (a), (b) [or], (c), (d) or (e) of this subdivision and who makes a referral of a

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patient to such health care provider discloses to the patient, in a brief and reasonable form and manner specified in regulations proposed by the commissioner after consultation with representatives of consumer and physician organizations and adopted by the public health council, subject to approval by the commissioner, the practitioner's, or family member's ownership interest or investment interest in the health care provider and the patient's right to utilize a specifically identified alternative health care provider if any such alternative is reasonably available.

§ 6. Section 6509-a of the education law, as amended by chapter 555 of the laws of 1993, is amended to read as follows: