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243 - Pharmaceutical Insurance Contract.

NY Elder L § 243 (2019) (N/A)
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(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 section two hundred forty-seven 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 eligible program participant;

(d) processing of claims for reimbursement to participating provider pharmacies pursuant to section two hundred fifty of this title;

(e) performing or causing to be performed utilization reviews for such purposes as may be required by the commissioner of health;

(f) conducting audits and surveys of participating provider pharmacies as specified pursuant to the terms and conditions of the contract; and

(g) 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 commissioner of health and shall maintain files in a manner and format approved by the commissioner. 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 commissioner of health shall permit.

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