STATE OF NEW YORK ________________________________________________________________________ 7142 2025-2026 Regular Sessions IN ASSEMBLY March 20, 2025 ___________ Introduced by M. of A. WALKER, DILAN, TAPIA, ALVAREZ, REYES, HYNDMAN, SEPTIMO, DE LOS SANTOS, ZACCARO, JACKSON, SANTABARBARA, TAYLOR, RIVERA, CRUZ -- read once and referred to the Committee on Insurance AN ACT to amend the insurance law and the public health law, in relation to requiring certain health insurance issuers to certify that at least a majority of prescription drug rebates are provided to patients at the point of sale The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. The insurance law is amended by adding a new section 3246 2 to read as follows: 3 § 3246. Ensuring fairness in certain cost sharing. (a) As used in this 4 section, the following terms shall have the following meanings: 5 (1) "Defined cost sharing" means a deductible payment or coinsurance 6 amount imposed on an enrollee for a covered prescription drug under the 7 enrollee's health plan. 8 (2) "Insurer" means any health insurance issuer that is subject to 9 state law regulating insurance and offers health insurance coverage, as 10 defined in 42 U.S.C. § 300gg-91, or any state or local governmental 11 employer plan. 12 (3) "Price protection rebate" means a negotiated price concession that 13 accrues directly or indirectly to the insurer, or other party on behalf 14 of the insurer, in the event of an increase in the wholesale acquisition 15 cost of a drug above a specified threshold. 16 (4) "Rebate" means: 17 (A) Negotiated price concessions including but not limited to base 18 price concessions, whether described as a rebate or otherwise, and 19 reasonable estimates of any price protection rebates and performance- 20 based price concessions that may accrue directly or indirectly to the 21 insurer during the coverage year from a manufacturer, dispensing pharma- EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD05948-01-5
A. 7142 2 1 cy, or other party in connection with the dispensing or administration 2 of a prescription drug, and 3 (B) Reasonable estimates of any negotiated price concessions, fees and 4 other administrative costs that are passed through, or are reasonably 5 anticipated to be passed through, to the insurer and serve to reduce the 6 insurer's liabilities for a prescription drug. 7 (b) An enrollee's defined cost sharing for each prescription drug 8 shall be calculated at the point of sale based on a price that is 9 reduced by an amount equal to at least eighty-five percent of all 10 rebates received, or to be received, in connection with the dispensing 11 or administration of the prescription drug. Nothing shall preclude an 12 insurer from decreasing an enrollee's defined cost sharing by an amount 13 greater than that required under this subsection. 14 (c) An insurer shall submit to the superintendent by the first of 15 January of each year a certification in a form to be established by the 16 superintendent attesting that it has complied with the requirements of 17 subsection (b) of this section for the prior calendar year. 18 (d) In complying with the provisions of this section, an insurer or 19 its agents shall not publish or otherwise publicly reveal information 20 regarding the actual amount of rebates an insurer receives on a product 21 or therapeutic class of products, manufacturer, or pharmacy-specific 22 basis. Such information shall be exempt from disclosure under section 23 eighty-seven of the public officers law and shall not be disclosed 24 directly or indirectly, or in a manner that would allow for the iden- 25 tification of an individual product, therapeutic class of products, or 26 manufacturer, or in a manner that would have the potential to compromise 27 the financial, competitive, or proprietary nature of such information. 28 An insurer shall impose the confidentiality protections of this subdivi- 29 sion on any vendor or downstream third-party that performs health care 30 or administrative services on behalf of the insurer that may receive or 31 have access to rebate information. 32 § 2. The insurance law is amended by adding a new section 4331 to read 33 as follows: 34 § 4331. Ensuring fairness in certain cost sharing. (a) As used in this 35 section, the following terms shall have the following meanings: 36 (1) "Defined cost sharing" means a deductible payment or coinsurance 37 amount imposed on an enrollee for a covered prescription drug under the 38 enrollee's health plan. 39 (2) "Corporation" means any health insurance issuer that is subject to 40 state law regulating insurance and offers health insurance coverage, as 41 defined in 42 U.S.C. § 300gg-91, or any state or local governmental 42 employer plan. 43 (3) "Price protection rebate" means a negotiated price concession that 44 accrues directly or indirectly to the corporation, or other party on 45 behalf of the corporation, in the event of an increase in the wholesale 46 acquisition cost of a drug above a specified threshold. 47 (4) "Rebate" means: 48 (A) Negotiated price concessions including but not limited to base 49 price concessions, whether described as a rebate or otherwise, and 50 reasonable estimates of any price protection rebates and performance- 51 based price concessions that may accrue directly or indirectly to the 52 corporation during the coverage year from a manufacturer, dispensing 53 pharmacy, or other party in connection with the dispensing or adminis- 54 tration of a prescription drug, and 55 (B) Reasonable estimates of any negotiated price concessions, fees and 56 other administrative costs that are passed through, or are reasonably
A. 7142 3 1 anticipated to be passed through, to the corporation and serve to reduce 2 the corporation's liabilities for a prescription drug. 3 (b) An enrollee's defined cost sharing for each prescription drug 4 shall be calculated at the point of sale based on a price that is 5 reduced by an amount equal to at least eighty-five percent of all 6 rebates received, or to be received, in connection with the dispensing 7 or administration of the prescription drug. Nothing shall preclude a 8 corporation from decreasing an enrollee's defined cost sharing by an 9 amount greater than that required under this subsection. 10 (c) A corporation shall submit to the superintendent by the first of 11 January of each year a certification in a form to be established by the 12 superintendent attesting that it has complied with the requirements of 13 subsection (b) of this section for the prior calendar year. 14 (d) In complying with the provisions of this section, a corporation or 15 its agents shall not publish or otherwise publicly reveal information 16 regarding the actual amount of rebates a corporation receives on a prod- 17 uct or therapeutic class of products, manufacturer, or pharmacy-specific 18 basis. Such information shall be exempt from disclosure under section 19 eighty-seven of the public officers law and shall not be disclosed 20 directly or indirectly, or in a manner that would allow for the iden- 21 tification of an individual product, therapeutic class of products, or 22 manufacturer, or in a manner that would have the potential to compromise 23 the financial, competitive, or proprietary nature of such information. A 24 corporation shall impose the confidentiality protections of this subdi- 25 vision on any vendor or downstream third-party that performs health care 26 or administrative services on behalf of the corporation that may receive 27 or have access to rebate information. 28 § 3. The public health law is amended by adding a new section 4417 to 29 read as follows: 30 § 4417. Ensuring fairness in certain cost sharing. 1. As used in this 31 section, the following terms shall have the following meanings: 32 (a) "Defined cost sharing" means a deductible payment or coinsurance 33 amount imposed on an enrollee for a covered prescription drug under the 34 enrollee's health plan. 35 (b) "Organization" means any health insurance issuer that is subject 36 to state law regulating insurance and offers health insurance coverage, 37 as defined in 42 U.S.C. § 300gg-91, or any state or local governmental 38 employer plan. 39 (c) "Price protection rebate" means a negotiated price concession that 40 accrues directly or indirectly to the organization, or other party on 41 behalf of the organization, in the event of an increase in the wholesale 42 acquisition cost of a drug above a specified threshold. 43 (d) "Rebate" means: 44 (i) Negotiated price concessions including but not limited to base 45 price concessions, whether described as a rebate or otherwise, and 46 reasonable estimates of any price protection rebates and performance- 47 based price concessions that may accrue directly or indirectly to the 48 organization during the coverage year from a manufacturer, dispensing 49 pharmacy, or other party in connection with the dispensing or adminis- 50 tration of a prescription drug, and 51 (ii) Reasonable estimates of any negotiated price concessions, fees 52 and other administrative costs that are passed through, or are reason- 53 ably anticipated to be passed through, to the organization and serve to 54 reduce the organization's liabilities for a prescription drug. 55 2. An enrollee's defined cost sharing for each prescription drug shall 56 be calculated at the point of sale based on a price that is reduced by
A. 7142 4 1 an amount equal to at least eighty-five percent of all rebates received, 2 or to be received, in connection with the dispensing or administration 3 of the prescription drug. Nothing shall preclude an organization from 4 decreasing an enrollee's defined cost sharing by an amount greater than 5 that required under this subdivision. 6 3. An organization shall submit to the superintendent by the first of 7 January of each year a certification in a form to be established by the 8 superintendent attesting that it has complied with the requirements of 9 subdivision two of this section for the prior calendar year. 10 4. In complying with the provisions of this section, an organization 11 or its agents shall not publish or otherwise publicly reveal information 12 regarding the actual amount of rebates an organization receives on a 13 product or therapeutic class of products, manufacturer, or pharmacy-spe- 14 cific basis. Such information shall be exempt from disclosure under 15 section eighty-seven of the public officers law and shall not be 16 disclosed directly or indirectly, or in a manner that would allow for 17 the identification of an individual product, therapeutic class of 18 products, or manufacturer, or in a manner that would have the potential 19 to compromise the financial, competitive, or proprietary nature of such 20 information. An organization shall impose the confidentiality 21 protections of this subdivision on any vendor or downstream third-party 22 that performs health care or administrative services on behalf of the 23 organization that may receive or have access to rebate information. 24 § 4. This act shall take effect immediately and apply to contracts 25 issued, renewed or amended on or after January 1, 2025.