N.Y. Comp. Codes R. & Regs. tit. 11 § 452.3

Current through Register Vol. 46, No. 43, October 23, 2024

Section 452.3 - Terms and conditions of contract relating to pharmacy benefit management services provided to health plans

(a) The disclosures provided for by Public Health Law section 280-a(2)(d) shall:

(1) be made by the pharmacy benefit manager within 30 days from receipt of a written request from the health plan, but such request shall not be made by the health plan more than once every six months;

(2) require that the contracts or arrangements requested be provided to the health plans in full and unredacted; and

(3) not apply to health plans that provide workers' compensation or automobile insurance.

(b) In the event that a health plan requests disclosure of a contract or arrangement that the pharmacy benefit manager determines is not related to the pharmacy benefit management services provided to the health plan, or that the pharmacy benefit manager determines contains information that is confidential, the pharmacy benefit manager may appeal to the department for a determination on disclosure.

(1) Application for a determination on disclosure. A pharmacy benefit manager shall file a letter setting forth all the relevant facts and circumstances that the department should consider in making the determination within 30 days from receipt of the written request from the health plan by sending such letter by electronic mail to the department at the address listed on the website of the department for such purpose. Such application shall also contain a copy of the unredacted contract that is at issue.

(2) Stay of obligation. Upon the filing of a complete application for a determination on disclosure, the obligation to respond to the health plan is stayed until a determination is rendered. An incomplete application shall have no such effect.

(3) Determination on disclosure. Upon receipt of a complete application, the department may seek additional information from the pharmacy benefit manager, the health plan, or any other party. Once the department determines that the department has sufficient information to render a determination, such determination shall be made in writing to the pharmacy benefit manager, and may direct the pharmacy benefit manager:

(i) to make the disclosure;

(ii) that it is not required to make the disclosure and to instead send a copy of the department's determination to be transmitted to the health plan; or

(iii) to make the disclosure with specific redactions.

(4) Information obtained by the department under this section shall be treated as information obtained under Insurance Law section 2904.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 452.3

Adopted New York State Register July 12, 2023/Volume XLV, Issue 28, eff. 7/12/2023