BILL NUMBER: S1267A
SPONSOR: BRESLIN
 
TITLE OF BILL:
An act to amend the insurance law and the public health law, in relation
to requiring a utilization review agent to follow certain rules when
establishing a step therapy protocol
 
PURPOSE OR GENERAL IDEA OF BILL:
The purpose of this bill is to require certain patient protections for
plans and utilization review agents to follow when establishing a step
therapy protocol.
 
SUMMARY OF PROVISIONS:
Section one amends section 4902 of the insurance law by adding two new
paragraphs (14) and (15) that require a utilization review agent, when
they are establishing a step therapy protocol, to ensure various proto-
cols. These include prohibiting a prescription drug that has not been
approved by the US FDA from being within a step therapy protocol. In
addition, a protocol cannot require an insured to try and fail on more
than one drug before providing coverage to the insured. A protocol
cannot require the use of a step therapy-required drug for longer than
30 days.
Section one also states that a protocol cannot be imposed on an insured
if they have taken the prescribed drug covered by a plan within the past
365 days. In addition, a step therapy protocol cannot require a newly
enrolled insured to repeat step therapy for a prescribed drug where they
have already completed a step therapy protocol for that drug under a
different plan. Finally, a protocol cannot impose on an insured a
prescribed drug that was previously approved by a plan for a specific
medical condition after the insured's plan implements a formulary
change.
This section also requires a utilization review agent to ensure that the
protocol accepts any attestation submitted by the insured's health care
professional stating that a required drug has failed.
Section two amends section 4903 of the insurance law to add that any
approval of a step therapy protocol override determination request must
be honored until 12 months after the date of approval or renewal of the
plan.
Section two also states that if a utilization review agent fails to
comply with any of the step therapy protocol requirements it will be
considered as a basis for granting an override of that step therapy
protocol.
Section three amends section 4902 of the public health law with the same
requirements as section one.
Section four amends section 4903 of the public health law with the same
requirements as section two.
Section five requires that this act shall take effect immediately.
 
JUSTIFICATION:
These additional patient protections are intended to ensure that
patients do not need to try and fail repeatedly on inappropriate medica-
tions and that step therapy protocols to do not cause significant delays
in access to the prescribed medication. Step therapy protocols that
ignore prior failures or cause long delays can result in adverse events,
including disease progression and relapse.
 
PRIOR LEGISLATIVE HISTORY:
S8191 - 2022
 
FISCAL IMPLICATIONS:
None
 
EFFECTIVE DATE:
This act shall take effect immediately.

Statutes affected:
S1267: 4902 insurance law, 4902(a) insurance law, 4902 public health law
S1267A: 4902 insurance law, 4902(a) insurance law, 4902 public health law