What's happening
This bill requires insurance policies covering prescription drugs to continue covering single source drugs during appeals if formulary changes occur.
Why it matters
Protects continuity of care. Ensures that patients who rely on unique, brand-name drugs (with no generic equivalent) are not forced to abruptly stop or switch medications if their insurer removes the drug from coverage, as long as an appeal or grievance is pending.
Limits insurer leverage during disputes. Prevents insurance companies from using formulary changes as a way to pressure patients to switch medications while an appeal is unresolved, which can be especially important for those with complex or rare conditions.
Reduces health risks and uncertainty. By maintaining coverage for these critical medications during the appeals process, the bill helps prevent potential negative health impacts, such as relapse or adverse reactions, that can result from forced medication changes.
Gives patients and providers a fairer process. Patients and their healthcare providers have more time to challenge formulary changes without risking loss of coverage, making it less likely that administrative decisions will override medical judgment during disputes.
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Who cares
Headline styles
Protect Single-Source Drug Coverage
Plain English, a few words. Used as the page title.
Sponsors
No co-sponsors yet.
History
- Referred to insurance
- Referred to insurance
Companion bill
The same bill in the other chamber. A bill becomes law when one version passes both houses and the governor signs it, so either number can carry it.
Protect Prescription Drug Coverage
In Assembly Committee · Insurance · Sponsor Philip Ramos
Full text
2 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
1893
2017-2018 Regular Sessions
IN SENATE
January 11, 2017
Introduced by Sen. AVELLA -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance
AN ACT to amend the insurance law, in relation to coverage for single source drugs
The People of the State of New York, represented in Senate and Assembly, do enact as follows:
Section 1. Subsection (i) of section 3216 of the insurance law is amended by adding a new paragraph 34 to read as follows:
(34) Every individual or blanket policy delivered or issued for delivery in this state providing coverage for prescription drugs through the use of a drug formulary shall include a provision which, in the event of a change to such formulary, allows a covered person who is taking a single source drug covered under such policy that is no longer included in or preferred under such formulary and has filed a grievance or an appeal of the denial of access to the drug with the insurer or a state or federal agency or designee of such agency, to continue receiving coverage for such drug under the same terms and conditions as would apply under the policy were such drug still included in or preferred under the formulary, until a final decision is rendered on the appeal or grievance. For the purpose of this paragraph, "single source drug" means a brandname drug for which there is no generic equivalent.
§ 2. Subsection (k) of section 3221 of the insurance law is amended by adding a new paragraph 22 to read as follows:
(22) Every group or blanket policy delivered or issued for delivery in this state providing coverage for prescription drugs through the use of a drug formulary shall include a provision which, in the event of a change to such formulary, allows a covered person who is taking a single source drug covered under such policy that is no longer included in or preferred under such formulary and has filed a grievance or an appeal of the denial of access to the drug with the insurer or a state or federal agency or designee of such agency, to continue receiving coverage for
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD00584-01-7
S. 1893 2
such drug under the same terms and conditions as would apply under the policy were such drug still included in or preferred under the formulary, until a final decision is rendered on the appeal or grievance. For the purpose of this paragraph, "single source drug" means a brandname drug for which there is no generic equivalent.
§ 3. Section 4303 of the insurance law is amended by adding a new subsection (oo) to read as follows:
(oo) Every contract delivered or issued for delivery in this state providing coverage for prescription drugs through the use of a drug formulary shall include a provision which, in the event of a change to such formulary, allows a covered person who is taking a single source drug covered under such contract that is no longer included in or preferred under such formulary and has filed a grievance or an appeal of the denial of access to the drug with the insurer corporation or organization certified pursuant to article forty-four of the public health law or a state or federal agency or designee of such agency, to continue receiving coverage for such drug under the same terms and conditions as would apply under the contract were such drug still included in or preferred under the formulary, until a final decision is rendered on the appeal or grievance. For the purpose of this subsection, "single source drug" means a brandname drug for which there is no generic equivalent.
§ 4. This act shall take effect on the first of the calendar month next succeeding the sixtieth day after it shall have become a law; provided, however, that this act shall apply only to policies and contracts issued, renewed or amended on or after such effective date.
Reflowed for reading: line numbers and page breaks removed. Cite the official text.
Sponsor's memo
Title of bill
An act to amend the insurance law, in relation to coverage for single source drugs
Purpose or general idea of the bill
The purpose of this legislation is to require continued coverage of a prescription drug if a patient was on such drug prior to a policy change.
Summary of provisions
Section 1 of the bill amends the adds a new paragraph 33 to subsection(i) 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.
Read the full memo (644 words)
Section 2 of the bill adds a new paragraph 21 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 (qq) 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
2015-16, S.695-A 2013-14, S.670/A.6130 (Ramos) 2011-12, S.7180/A.3718 (Rivera) (Enacting Clause Stricken) 2009-10, 5.5510 (Klein)/A.4191 (Rivera) 2007-08, A.6739 (Rivera) 2005-06, S.4084 (Alesi)/A.3035 (Rivera) 2003-04, S.4904-A (Alesi)/A.6012-A (Rivera) 2001-02, S.6588-8 (Alesi)/A.1912-C (Rivera) 1999-00, A.9448 (Colman)
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.
Summaries, headlines and scores are AI-generated from the official bill text. How we score bills. Source: NYS Open Legislation.