LEGISLATIVE FISCAL ESTIMATE
[Second Reprint]
SENATE, No. 2019
STATE OF NEW JERSEY
221st LEGISLATURE
DATED: JULY 3, 2025
SUMMARY
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Synopsis: |
Authorizes pharmacists to dispense HIV prophylaxis without individual prescription under certain circumstances; mandates prescription benefits coverage. |
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Type of Impact: |
Annual net increase in State expenditures and increase in State revenues; annual net increase in local government expenditures. |
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Agencies Affected: |
Department of Human Services; Division of Pensions and Benefits in the Department of the Treasury; certain local governments. |
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Fiscal Impact |
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Annual |
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Net State Expenditure Increase |
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Indeterminate |
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State Revenue Increase |
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Indeterminate |
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Net Local Expenditure Increase |
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Indeterminate |
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· The Office of Legislative Services (OLS) concludes that authorizing pharmacists to dispense HIV prophylaxis to a patient once every two years without an individual prescription, when certain conditions are met, will increase annual State expenditures under the NJ FamilyCare program. These costs would concomitantly increase annual State revenue in the form of federal Medicaid cost reimbursements.
· The OLS anticipates that requiring the State Health Benefits Program and the School Employees’ Health Benefits Program to provide coverage for HIV prophylaxis dispensed to a member once every two years without an individual prescription may increase State and local government expenditures by an indeterminate amount if more brand drugs are issued as a result of the bill.
BILL DESCRIPTION
This bill authorizes pharmacists to dispense HIV prophylaxis without an individual prescription when a standing order has been issued to a pharmacist from an authorizing entity and the pharmacist has completed a State approved training and certifying that the pharmacist will adhere to certain practices and requirements regarding the dispensation of prophylaxis to a patient.
Under the bill, a pharmacist may furnish a patient without a prescription no more than a 90-day supply of HIV prophylaxis within any given two-year period when certain other conditions are met.
The bill requires health benefits plans delivered, issued, executed, or renewed in this State that include prescription drug benefits, including plans authorized by the State Health Benefits Program, the School Employees’ Health Benefits Program by extension, and NJ FamilyCare (the State’s Medicaid program), to provide coverage for HIV prophylaxis without any prior authorization or step therapy requirements, unless the federal Food and Drug Administration authorizes or approves therapeutic equivalents and the health plan provides coverage for at least one version of HIV prophylaxis without prior authorization or step therapy.
The bill also requires health plans, other than those authorized by the State Health Benefits Program and the School Employees’ Health Benefits Program, to reimburse pharmacists for the provision of HIV prophylaxis at a rate that is no less than the rate provided by the plan to other non-physician practitioners, if the service or procedure is within the scope of practice of the treating pharmacist, and the service or procedure would otherwise be covered under the health benefits plan if provided by a healthcare provider.
Additionally, the bill requires a health benefits plan to grant a licensed pharmacist receiving reimbursement under the bill’s provisions the same rights of participation, plan admission, and registration as those granted to a healthcare provider who is reimbursed for an identical service.
Lastly, the bill requires the State Health Benefits Commission to provide prescription drug benefits coverage for HIV prophylaxis to the same extent as any other medical condition.
FISCAL ANALYSIS
EXECUTIVE BRANCH
None received.
OFFICE OF LEGISLATIVE SERVICES
The OLS concludes that issuing a standing order authorizing pharmacists to dispense HIV prophylaxis to a patient once every two years without an individual prescription, when certain conditions are met, will increase State expenditures and annual State revenue in the form of federal Medicaid cost reimbursements under the NJ FamilyCare Program. Under the standing order it is assumed that the use of HIV prophylaxis by NJ FamilyCare enrollees would grow, by an unpredictable amount, thereby leading to an indeterminate increase in NJ FamilyCare costs. These costs would concomitantly increase annual State revenue in the form of federal Medicaid cost reimbursements.
The OLS does not anticipate that limiting the use of prior authorization or step therapy requirements will impact NJ FamilyCare costs since the program has been prohibited from imposing these requirements on HIV prophylaxis since FY 2023.
The OLS anticipates that requiring the State Health Benefits Program and the School Employees’ Health Benefits Program to provide coverage for HIV prophylaxis dispensed to a member once every two years without an individual prescription may increase State and local government expenditures by an indeterminate amount if more brand drugs are issued as a result of the bill.
The OLS does not and cannot know the number of members who will request a pharmacist to dispense HIV prophylaxis for them without a prescription, but notes that the State Health Benefits Program and the School Employees’ Health Benefits Program already provide coverage for brand and generic HIV prophylaxis medications at the same rate as other prescription drugs. This suggests that the programs will be able to continue imposing prior authorization requirements on at least one version of the medication.
The OLS does not anticipate that this bill will have a significant impact on the medication-seeking behavior of persons covered by the State Health Benefits Program or School Employees’ Health Benefits Program.
For covered members requesting HIV prophylaxis pre-exposure, the OLS anticipates that the member’s primary care provider would write the individual a prescription for the medication and likely route the request through the pharmacy benefit manager’s prior authorization process. This would result in the same $0 cost to the member if the plan’s current cost sharing requirements remain in place.
For covered members requesting HIV prophylaxis post-exposure, which the bill defines as exposure to HIV having occurred within the previous 72 hours consistent with the federal Centers for Disease Control and Prevention guidelines, the OLS anticipates that most covered persons are receiving and will continue to receive the medication at the same rate as the cost sharing provisions that apply to other prescription drugs covered by the plan.
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Section: |
State Government |
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Analyst: |
Associate Fiscal Analyst |
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Approved: |
Thomas Koenig Legislative Budget and Finance Officer |
This legislative fiscal estimate has been produced by the Office of Legislative Services due to the failure of the Executive Branch to respond to our request for a fiscal note.
This fiscal estimate has been prepared pursuant to P.L.1980, c.67 (C.52:13B-6 et seq.).