Drug Price Increase Reporting

I. Introduction

Pursuant to New York State Insurance Law section 111-A(b), prescription drug manufacturers are required to report drug price increases with the Department of Financial Service (DFS) when the price increase meets the following criteria:

  • When the prescription drug’s wholesale acquisition (WAC) cost is more than $40 for a course of therapy, and
  • The prescription drug’s WAC price increase is more than 16% percent, or
  • The cumulative WAC increases, including the current reported increase, within the previous 24 months is more than 16%.

When these criteria are met, the Manufacturer must notify DFS 60 days prior to the effective date of the increase using this submission form.

NOTE: If you have more than 6 drugs to report, download and populate the Drug Price Increase Reporting Tool (.xlsx) and attach it to your submission at the bottom of this form.

These price increases will be posted within five days of receipt of the notification.

Learn more about drug price filing requirements on our Prescription Drug Manufacturers page.

If you have questions about a filing, email DFS at [email protected].

II. Drug Information

Drug Number

NDC Code
Instructions
You must enter an 11-digit code.

Manufacturer Name *

* NOTE: If the manufacturer name is different from the name on the drug label please also include the name of the drug labeler.

Drug Product Name

Strength

Dosage Form

Package Size

Date Reported
Instructions
Date of the submission of this report.
Current Wholesale Acquisition Cost
Instructions
Wholesale Acquisition Cost of drug before reported increase.
Effective Date of Increase
NOTE
This date should not be prior to August 18, 2024.
Wholesale Acquisition Cost After Increase
Instructions
Wholesale Acquisition Cost of drug after the reported increase.

Dollar Amount of Increase

Percentage Increase
Instructions
The percentage that the Wholesale Acquisition Cost will increase after the reported increase.
Cumulative Percentage Increase
Instructions
The percentage that the Wholesale Acquisition Cost has increased in the prior 24 months including the reported increase.
Is there less than 60 days between the reporting date and the effective date of the increase?
Instructions

Please select "Yes" or "No" in the drop-down boxes of the columns in use.

If Yes, please provide an explanation as to why.

Is there a Change or Improvement to the Drug that Necessitates the Price Increase?  NOTE: These fields are required.
Instructions

Please select "Yes" or "No" in the drop-down boxes of the columns in use.

If "Yes", please explain.

If you need to provide more information, please upload your document at the end of this form.

Does your submission contain any information reasonably designated as a Trade Secret?  NOTE: These fields are required.
Instructions

Please select "Yes" or "No" in the drop-down boxes of the columns in use.

If "Yes", please explain.

Please specify what information you are designating a trade secret.

If you need to provide more information, please upload your information as a document at the end of this form.
 

III. Contact Information

Submission

By checking the following box, I swear and affirm, under penalty of perjury, that the statements made in this drug price increase report have been examined by me and to the best of my knowledge and belief are true, correct, and complete.  I understand that false statements made herein are punishable as a Class A misdemeanor pursuant to section 210.45 of the Penal Law.
Maximum 5 files.
256 MB limit.
Allowed types: txt rtf pdf doc docx odt ppt pptx odp xls xlsx ods.