Provides that every insurance policy which provides coverage for prescription drugs shall insure that there is continuous coverage of a single source drug that is part of a prescribed therapy until such prescribed therapy is no longer medically necessary for the enrollee of such policy; defines "single source drug".
NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
BILL NUMBER: A1287
SPONSOR: Ramos TITLE OF BILL:
An act to amend the insurance law, in relation to coverage for single
source drugs
SUMMARY OF SPECIFIC PROVISIONS:
Section one adds a new paragraph, 40 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. Section two adds a new paragraph
24 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
three adds a new subsection ww to § 4303 of the insurance law requiring
contracts delivered or issued for delivery in this state providing
coverage for prescription drugs 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 four contains the effective
date.
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 during 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:
A.4494 of 2023-24 referred to insurance
A.5032 of 2021-22 referred to insurance
A.4899a of 2019-20 amend and recommit to insurance
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.
