What's happening
This bill requires health insurance plans in New York to continue covering single source drugs during formulary changes if the patient appeals the denial.
Why it matters
Protects continuity of care for patients. who rely on single source (brand name, no generic) drugs by preventing abrupt loss of coverage if their insurer changes the drug formulary and the patient is contesting the change.
Reduces risk of treatment disruption. for individuals with complex or chronic conditions, as their medication coverage is maintained under the same terms during the appeals or grievance process.
Levels the playing field between insurers and patients. by requiring coverage to continue until a final decision is made, rather than allowing insurers to deny access mid-appeal, which can discourage patients from pursuing their rights.
Applies to a wide range of insurance plans. (individual, group, blanket, and health maintenance organization contracts), ensuring broad protection across the state for those affected by formulary changes.
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Who cares
Headline styles
Protect Access to Brand-Name Drugs
Plain English, a few words. Used as the page title.
Sponsors
No co-sponsors yet.
History
- Print number 4899a
- Amend and recommit to insurance
- 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.
Keep Drug Coverage During Appeals
In Senate Committee · Insurance · Sponsor Kevin S. Parker
Full text
2 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
4899--A
2019-2020 Regular Sessions
IN ASSEMBLY
February 5, 2019
Introduced by M. of A. RAMOS -- read once and referred to the Committee on Insurance -- 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
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 36 to read as follows:
(36) 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
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD07563-02-0
A. 4899--A 2
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.
§ 3. Section 4303 of the insurance law is amended by adding a new subsection (ss) to read as follows:
(ss) 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.
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