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.
STATE OF NEW YORK
________________________________________________________________________
1287
2025-2026 Regular Sessions
IN ASSEMBLY
January 9, 2025
___________
Introduced by M. of A. RAMOS -- read once and referred 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 Assem-bly, do enact as follows:
1 Section 1. Subsection (i) of section 3216 of the insurance law is
2 amended by adding a new paragraph 40 to read as follows:
3 (40) Every individual or blanket policy delivered or issued for deliv-
4 ery in this state providing coverage for prescription drugs through the
5 use of a drug formulary shall include a provision which, in the event of
6 a change to such formulary, allows a covered person who is taking a
7 single source drug covered under such policy that is no longer included
8 in or preferred under such formulary and has filed a grievance or an
9 appeal of the denial of access to the drug with the insurer or a state
10 or federal agency or designee of such agency, to continue receiving
11 coverage for such drug under the same terms and conditions as would
12 apply under the policy were such drug still included in or preferred
13 under the formulary, until a final decision is rendered on the appeal or
14 grievance. For the purpose of this paragraph, "single source drug" means
15 a brandname drug for which there is no generic equivalent.
16 § 2. Subsection (k) of section 3221 of the insurance law is amended by
17 adding a new paragraph 24 to read as follows:
18 (24) Every group or blanket policy delivered or issued for delivery in
19 this state providing coverage for prescription drugs through the use of
20 a drug formulary shall include a provision which, in the event of a
21 change to such formulary, allows a covered person who is taking a single
22 source drug covered under such policy that is no longer included in or
23 preferred under such formulary and has filed a grievance or an appeal of
24 the denial of access to the drug with the insurer or a state or federal
25 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.
LBD02413-01-5
A. 1287 2
1 such drug under the same terms and conditions as would apply under the
2 policy were such drug still included in or preferred under the formu-
3 lary, until a final decision is rendered on the appeal or grievance. For
4 the purpose of this paragraph, "single source drug" means a brandname
5 drug for which there is no generic equivalent.
6 § 3. Section 4303 of the insurance law is amended by adding a new
7 subsection (ww) to read as follows:
8 (ww) Every contract delivered or issued for delivery in this state
9 providing coverage for prescription drugs through the use of a drug
10 formulary shall include a provision which, in the event of a change to
11 such formulary, allows a covered person who is taking a single source
12 drug covered under such contract that is no longer included in or
13 preferred under such formulary and has filed a grievance or an appeal of
14 the denial of access to the drug with the insurer corporation or organ-
15 ization certified pursuant to article forty-four of the public health
16 law or a state or federal agency or designee of such agency, to continue
17 receiving coverage for such drug under the same terms and conditions as
18 would apply under the contract were such drug still included in or
19 preferred under the formulary, until a final decision is rendered on the
20 appeal or grievance. For the purpose of this subsection, "single source
21 drug" means a brandname drug for which there is no generic equivalent.
22 § 4. This act shall take effect on the first of the calendar month
23 next succeeding the sixtieth day after it shall have become a law;
24 provided, however, that this act shall apply only to policies and
25 contracts issued, renewed or amended on or after such effective date.
