§ 243 — Pharmaceutical insurance contract

§ 243. Pharmaceutical insurance contract. 1. The commissioner of\nhealth shall, subject to the approval of the director of the budget,\nenter into a contract with one or more contractors to assist in carrying\nout the provisions of this title. Such contractual arrangements shall be\nmade subject to a competitive process pursuant to the state finance law\nand shall ensure that state payments for the contractor's necessary and\nlegitimate expenses for the administration of this program are limited\nto the amount specified in advance, and that such payments shall not\nexceed the amount appropriated therefor in any fiscal year. The\ncommissioner shall review the contract pricing provisions to assure that\nthe level of contract payments are in the best interest of the state,\ngiving consideration to the total level of participant enrollment\nachieved, the volume of claims processed, and such other factors as may\nbe relevant in order to contain state expenditures. In the event that\nthe commissioner determines that the contract payment provisions do not\nprotect the interest of the state, the commissioner shall initiate\ncontract negotiations for the purpose of modifying contract payments\nand/or scope requirements.\n 2. The responsibilities of the contractor or contractors shall\ninclude, but need not be limited to:\n (a) providing for a method of determining, on an annual basis and upon\ntheir application therefor, the eligibility of persons pursuant to\nsection two hundred forty-two of this title within a reasonable period\nof time, including alternative methods for such determination of\neligibility, such as through the mail or home visits, where reasonable\nand/or necessary, and for notifying applicants of such eligibility\ndeterminations;\n (b) notifying each eligible program participant in writing upon the\ncommencement of the annual coverage period of such participant's\ncost-sharing responsibilities pursuant to section two hundred\nforty-seven of this title. The contractor shall also notify each\neligible program participant of any adjustment of the co-payment\nschedule by mail no less than thirty days prior to the effective date of\nsuch adjustments and shall inform such eligible program participants of\nthe date such adjustments shall take effect;\n (c) issuing an identification card to each eligible program\nparticipant;\n (d) processing of claims for reimbursement to participating provider\npharmacies pursuant to section two hundred fifty of this title;\n (e) performing or causing to be performed utilization reviews for such\npurposes as may be required by the commissioner of health;\n (f) conducting audits and surveys of participating provider pharmacies\nas specified pursuant to the terms and conditions of the contract; and\n (g) coordinating coverage with insurance companies and other public\nand private organizations offering such coverage for those eligible\nprogram participants having partial coverage for covered drugs through\nthird-party sources, and providing for recoupment of any duplicate\nreimbursement paid by the state on behalf of such eligible program\nparticipants.\n 3. The contractor or contractors shall be required to provide such\nreports as may be deemed necessary by the commissioner of health and\nshall maintain files in a manner and format approved by the\ncommissioner.\n 4. The contractor or contractors may contract with private\nnot-for-profit or proprietary corporations, or with entities of local\ngovernment within the state of New York, to perform such obligations of\nthe contractor or contractors as the commissioner of health shall\npermit.\n