Requires health plan coverage to include generic drugs and biosimilars where the wholesale acquisition cost of such generic drugs or biosimilars is lower than the brand drug's wholesale acquisition cost.
Impact
The bill is expected to have significant implications on state health insurance regulations by enhancing the accessibility of generic medications for consumers. By ensuring that lower-cost alternatives are readily available without additional barriers such as prior authorizations or step therapy, A11256 aims to facilitate broader access to affordable medications. This could potentially lead to lower out-of-pocket costs for patients and influence overall healthcare expenditure in New York.
Summary
A11256 is a proposed amendment to the New York insurance law aimed at requiring health plans to cover certain generic drugs and biosimilars at cost-effective rates. Specifically, the bill mandates that if the wholesale acquisition cost of a generic drug or biosimilar is lower than that of the reference brand drug, health plans must make these alternatives available in their formularies with favorable cost-sharing provisions. This includes prohibiting prior authorization requirements that would restrict access to these drugs compared to the brand-name counterparts.
Contention
However, the bill may face contention among various stakeholders, particularly from pharmaceutical companies who might oppose limitations on the promotion of brand-name drugs. Critics of the legislation may argue that stringent rules on coverage could undermine innovation in drug development and put financial pressure on companies. Additionally, there may be concerns about the standards maintaining safety and efficacy regarding the replacements provided through the mandate, emphasizing the ongoing debate about biological equivalents such as biosimilars.
Enacts the New York state pharmaceutical drug manufacturer and wholesaler disclosure act; requires pharmaceutical drug manufacturers and wholesalers to annually report to the New York department of health, for disclosure to the general public, all of its gifts to health care practitioners that prescribe drugs when such gifts have a value of seventy-five dollars or more; authorizes the commissioner of health to impose penalties and promulgate necessary rules and regulations.
To Mandate The Use Of Biosimilar Medicines Under Health Benefit Plans; To Require A Healthcare Provider To Prescribe Biosimilar Medicines; And To Improve Access To Biosimilar Medicines.
Requires insurers to cover the substitution of a brand name prescription drug when the federal food and drug administration has declared that there is a supply issue with a generic drug.
Requires a pharmacy benefit manager to pay a participating pharmacy at minimum at the national average drug acquisition cost (NADAC) rate, or at the pharmacy acquisition cost rate if greater or there is not a NADAC rate, plus a professional dispensing fee that is at minimum the professional dispensing fee paid under the state medical assistance program.