NY A09265

Requires insurers and health maintenance organizations to establish written procedures for notifying patients of adverse step therapy override determinations, with notices sent to the insured/enrollee, their authorized representative, and prescribing healthcare professional.

Mandates adverse determination notices include the reasons for denial and clinical rationale, instructions on how to appeal through standard, expedited, and external appeal processes, and information on alternative covered medications and clinical review criteria used.

Requires notices to specify any additional information needed by the utilization review agent to render an appeal decision.

Applies requirements to both insurance law (for health insurers) and public health law (for health maintenance organizations).

Takes effect 90 days after becoming law, with regulatory agencies authorized to implement necessary rules immediately.