New York Laws
Article 43 - Non-Profit Medical and Dental Indemnity, or Health and Hospital Service Corporations
4329 - Prescription Drug Coverage.

(b) (1) Every contract issued by a corporation subject to the
provisions of this article that provides coverage for prescription drugs
shall include in the contract a process that allows an insured, the
insured's designee, or the insured's prescribing health care provider to
request a formulary exception. With respect to the process for such a
formulary exception, a corporation shall follow the process and
procedures specified in article forty-nine of this chapter and article
forty-nine of the public health law, except as otherwise provided in
paragraphs two, three, four and five of this subsection.
(2) (A) A corporation shall have a process for an insured, the
insured's designee, or the insured's prescribing health care provider to
request a standard review that is not based on exigent circumstances of
a formulary exception for a prescription drug that is not covered by the
contract.
(B) A corporation shall make a determination on a standard exception
request that is not based on exigent circumstances and notify the
insured or the insured's designee and the insured's prescribing health
care provider by telephone of its coverage determination no later than
seventy-two hours following receipt of the request.
(C) A corporation that grants a standard exception request that is not
based on exigent circumstances shall provide coverage of the
non-formulary prescription drug for the duration of the prescription,
including refills.
(D) For the purpose of this subsection, "exigent circumstances" means
when an insured is suffering from a health condition that may seriously
jeopardize the insured's life, health, or ability to regain maximum
function or when an insured is undergoing a current course of treatment
using a non-formulary prescription drug.
(3) (A) A corporation shall have a process for an insured, the
insured's designee, or the insured's prescribing health care provider to
request an expedited review based on exigent circumstances of a
formulary exception for a prescription drug is not covered by the
contract.
(B) A corporation shall make a determination on an expedited review
request based on exigent circumstances and notify the insured or the
insured's designee and the insured's prescribing health care provider by
telephone of its coverage determination no later than twenty-four hours
following receipt of the request.
(C) A corporation that grants an exception based on exigent
circumstances shall provide coverage of the non-formulary prescription
drug for the duration of the exigent circumstances.
(4) A corporation that denies an exception request under paragraph two
or three of this subsection shall provide written notice of its
determination to the insured or the insured's designee and the insured's
prescribing health care provider within three business days of receipt
of the exception request. The written notice shall be considered a final
adverse determination under section four thousand nine hundred four of

this chapter or section four thousand nine hundred four of the public
health law. Written notice shall also include the name or names of
clinically appropriate prescription drugs covered by the corporation to
treat the insured.
(5) (A) If a corporation denies a request for an exception under
paragraph two or three of this subsection, the insured, the insured's
designee, or the insured's prescribing health care provider shall have
the right to request that such denial be reviewed by an external appeal
agent certified by the superintendent pursuant to section four thousand
nine hundred eleven of this chapter in accordance with article
forty-nine of this chapter and article forty-nine of the public health
law.
(B) An external appeal agent shall make a determination on the
external appeal and notify the corporation, the insured or the insured's
designee, and the insured's prescribing health care provider by
telephone of its determination no later than seventy-two hours following
the external appeal agent's receipt of the request, if the original
request was a standard exception request under paragraph two of this
subsection. The external appeal agent shall notify the corporation, the
insured or the insured's designee and the insured's prescribing health
care provider in writing of the external appeal determination within two
business days of rendering such determination.
(C) An external appeal agent shall make a determination on the
external appeal and notify the corporation, the insured or the insured's
designee, and the insured's prescribing health care provider by
telephone of its determination no later than twenty-four hours following
the external appeal agent's receipt of the request, if the original
request was an expedited exception request under paragraph three of this
subsection and the insured's prescribing health care provider attests
that exigent circumstances exist. The external appeal agent shall notify
the corporation, the insured or the insured's designee and the insured's
prescribing health care provider in writing of the external appeal
determination within seventy-two hours of the external appeal agent's
receipt of the external appeal.
(D) An external appeal agent shall make a determination in accordance
with subparagraph (A) of paragraph four of subsection (b) of section
four thousand nine hundred fourteen of this chapter and subparagraph (A)
of paragraph (d) of subdivision two of section four thousand nine
hundred fourteen of the public health law. When making a determination,
the external appeal agent shall consider whether the formulary
prescription drug covered by the corporation will be or has been
ineffective, would not be as effective as the non-formulary prescription
drug, or would have adverse effects.
(E) If an external appeal agent overturns the corporation's denial of
a standard exception request under paragraph two of this subsection,
then the corporation shall provide coverage of the non-formulary
prescription drug for the duration of the prescription, including
refills. If an external appeal agent overturns the corporation's denial
of an expedited exception request under paragraph three of this
subsection, then the corporation shall provide coverage of the
non-formulary prescription drug for the duration of the exigent
circumstances.
* (c) (1) Except as otherwise provided in paragraph three of this
subsection, a corporation shall not:
(A) remove a prescription drug from a formulary;
(B) move a prescription drug to a tier with a larger deductible,
copayment, or coinsurance if the formulary includes two or more tiers of

benefits providing for different deductibles, copayments or coinsurance
applicable to the prescription drugs in each tier; or
(C) add utilization management restrictions to a prescription drug on
a formulary, unless such changes occur at the time of enrollment,
issuance or renewal of coverage.
(2) Prohibitions provided in paragraph one of this subsection shall
apply beginning on the date on which a plan year begins and through the
end of such plan year.
(3) (A) A corporation with a formulary that includes two or more tiers
of benefits providing for different deductibles, copayments or
coinsurance applicable to prescription drugs in each tier may move a
prescription drug to a tier with a larger deductible, copayment or
coinsurance if an AB-rated generic equivalent or interchangeable
biological product for such prescription drug is added to the formulary
at the same time.
(B) A corporation may remove a prescription drug from a formulary if
the federal Food and Drug Administration determines that such
prescription drug should be removed from the market, including new
utilization management restrictions issued pursuant to federal Food and
Drug Administration safety concerns.
(C) A corporation with a formulary that includes two or more tiers of
benefits providing for different copayments applicable to prescription
drugs may move a prescription drug to a tier with a larger copayment
during the plan year, provided the change is not applicable to an
insured who is already receiving such prescription drug or has been
diagnosed with or presented with a condition on or prior to the start of
the plan year that is treated by such prescription drug or is a
prescription drug that is or would be part of the insured's treatment
regimen for such condition.
(4) A corporation shall provide notice to insureds of the intent to
remove a prescription drug from a formulary or alter deductible,
copayment or coinsurance requirements in the upcoming plan year, ninety
days prior to the start of the plan year. Such notice of impending
formulary and deductible, copayment or coinsurance changes shall also be
posted on the corporation's online formulary and in any prescription
drug finder system that the corporation provides to the public.
(5) The provisions of this subsection shall not supersede the terms of
a collective bargaining agreement, or the rights of labor representation
groups to collectively bargain changes to the formularies.
* NB There are 2 sb (c)'s
* (c) Every contract issued by a corporation subject to the provisions
of this article that provides coverage for prescription drugs shall
include in the contract a process that allows an insured, the insured's
designee, or the insured's prescribing health care provider to
immediately obtain, on the insured's behalf, an additional thirty-day
supply of any current prescription of the insured, except as provided in
section two hundred seventy-eight-a of the public health law, at the
same level of coverage as a normal refill of such prescription drug upon
the declaration of a state disaster emergency pursuant to section
twenty-eight of the executive law.
* NB There are 2 sb (c)'s