§ 243. Pharmaceutical insurance contract. 1. The elderly
pharmaceutical insurance coverage panel, established pursuant to section
two hundred forty-four of this title shall, subject to the approval of
the director of the budget, enter into a contract with one or more
contractors to assist in carrying out the provisions of this title. Such
contractual arrangements shall be made subject to a competitive process
pursuant to the state finance law and shall ensure that state payments
for the contractor's necessary and legitimate expenses for the
administration of this program are limited to the amount specified in
advance, and that such payments shall not exceed the amount appropriated
therefor in any fiscal year. The panel shall, at each of its regularly
scheduled meetings, review the contract pricing provisions to assure
that the level of contract payments are in the best interest of the
state, giving consideration to the total level of participant enrollment
achieved, the volume of claims processed, and such other factors as may
be relevant in order to contain state expenditures. In the event that
the panel determines that the contract payment provisions do not protect
the interest of the state, the executive director shall initiate
contract negotiations for the purpose of modifying contract payments
and/or scope requirements.
2. The responsibilities of the contractor or contractors shall
include, but need not be limited to:
(a) providing for a method of determining, on an annual basis and upon
their application therefor, the eligibility of persons pursuant to
section two hundred forty-two of this title within a reasonable period
of time, including alternative methods for such determination of
eligibility, such as through the mail or home visits, where reasonable
and/or necessary, and for notifying applicants of such eligibility
determinations;
(b) notifying each eligible program participant in writing upon the
commencement of the annual coverage period of such participant's
cost-sharing responsibilities pursuant to sections two hundred
forty-seven and two hundred forty-eight of this title. The contractor
shall also notify each eligible program participant of any adjustment of
the co-payment schedule by mail no less than thirty days prior to the
effective date of such adjustments and shall inform such eligible
program participants of the date such adjustments shall take effect;
(c) issuing an identification card to each program participant who is
eligible to purchase prescribed covered drugs for an amount specified
pursuant to subdivision three of section two hundred forty-seven or
subdivision three of section two hundred forty-eight of this title. The
dates of the annual coverage period shall be imprinted on the card. When
an eligible program participant meets the annual limits on point of sale
co-payments set forth in subdivision four of section two hundred
forty-seven or subdivision four of section two hundred forty-eight of
this title, either new identification cards shall be issued to such
participant indicating waiver of such co-payment requirements for the
remainder of the annual coverage period or the contractor shall develop
and implement an alternative method to permit the purchase of covered
drugs without a co-payment requirement;
(d) developing and implementing the system for those individuals
electing the deductible option to record their personal covered drug
expenditures in accordance with subdivision three of section two hundred
forty-eight of this title. Such recordkeeping system shall be provided
to each such participant at a nominal charge which shall be subject to
the approval of the panel. The contractor shall also reimburse
participants for personal covered drug expenditures made in excess of
their deductible requirements, less the co-payments required by
subdivision four of section two hundred forty-eight of this title, made
prior to their receipt of an identification card issued in accordance
with paragraph (c) of this subdivision;
(e) processing of claims for reimbursement to participating provider
pharmacies pursuant to section two hundred fifty of this title;
(f) performing or causing to be performed utilization reviews for such
purposes as may be required by the elderly pharmaceutical insurance
coverage panel;
(g) conducting audits and surveys of participating provider pharmacies
as specified pursuant to the terms and conditions of the contract; and
(h) coordinating coverage with insurance companies and other public
and private organizations offering such coverage for those eligible
program participants having partial coverage for covered drugs through
third-party sources, and providing for recoupment of any duplicate
reimbursement paid by the state on behalf of such eligible program
participants.
3. The contractor or contractors shall be required to provide such
reports as may be deemed necessary by the elderly pharmaceutical
insurance coverage panel and shall maintain files in a manner and format
approved by the executive director.
4. The contractor or contractors may contract with private
not-for-profit or proprietary corporations, or with entities of local
government within the state of New York, to perform such obligations of
the contractor or contractors as the elderly pharmaceutical insurance
coverage panel shall permit.
Last modified: November 19, 2006