2006 New York Code - Pharmaceutical Insurance Contract.

 
    §   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.