Sponsored by:
Assemblyman HERB CONAWAY, JR.
District 7 (Burlington)
Assemblyman STERLEY S. STANLEY
District 18 (Middlesex)
SYNOPSIS
Requires health insurance carriers to provide list of alternative drugs to health care professionals, pharmacists, and covered persons under certain circumstances.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning prescription drug benefit coverage and supplementing P.L.1997, c.192 (C.26:2S-1 et al.).
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. a. A carrier that offers a health benefits plan in this State which provides coverage for pharmacy services, prescription drugs, or for participation in a prescription drug plan, shall provide to a pharmacist in a situation in which the carrier denies a covered person’s coverage for a drug prescribed by the health care professional, a list of all alternative drugs that are covered by the health benefits plan and that are interchangeable with, and therapeutically equivalent to, the drug for which coverage was denied. The carrier shall provide the list of alternative drugs to the pharmacy point of sale system at the time of denial, along with the notice of the denial of coverage.
b. For purposes of this section, “health care professional” means a person licensed to practice a health care profession pursuant to Title 45 of the Revised Statutes.
"Carrier" means any entity that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a hospital or health service corporation, a multiple employer welfare arrangement, an entity under contract with the State Health Benefits Program or the School Employees' Health Benefits Program to administer a health benefits plan, an entity under contract with the Division of Medical Assistance and Health Services in the Department of Human Services to provide benefits to persons who are eligible for Medicaid under P.L.1968, c.413 (C.30:4D-1 et seq.), or any other entity providing a health benefits plan.
"Pharmacist" means an individual currently licensed by this State to engage in the practice of pharmacy.
2. This act shall take effect on the 90th day next following the date of enactment.
STATEMENT
This bill supplements the “Health Care Quality Act” to require a carrier that offers a health benefits plan in this State which provides coverage for pharmacy services, prescription drugs, or for participation in a prescription drug plan, to provide to a pharmacist in a situation in which the carrier denies a covered person’s coverage for a drug prescribed by the health care professional, a list of all alternative drugs that are covered by the health benefits plan and that are interchangeable with, and therapeutically equivalent to, the drug for which coverage was denied. The carrier is to provide the list of alternative drugs to the pharmacy point of sale system at the time of denial, along with the notice of the denial of coverage along with the notice of the denial of coverage.