ASSEMBLY FINANCIAL INSTITUTIONS AND INSURANCE COMMITTEE

STATEMENT TO

ASSEMBLY, No. 4657

STATE OF NEW JERSEY

DATED: MAY 14, 2026

      The Assembly Financial Institutions and Insurance Committee reports favorably Assembly Bill No. 4657.

      This bill requires pharmacy benefits managers to make certain disclosures to health benefits plan sponsors and provides plan sponsors with certain rights to audit pharmacy benefits managers. 

      Specifically, the bill requires pharmacy benefits managers to submit reports to the plan sponsor and the department not less frequently than every six months.  Each report is to be made available to the plan sponsor in plain language, in a machine-readable format, and as the department may determine, other formats.

      The bill requires the reports to contain a list of drugs for which a claim was filed and, with respect to each drug on that list:

      (1)  the contracted compensation paid by the plan sponsor for each covered drug, identified by National Drug Code, to the pharmacy benefits manager;

      (2)  the contracted compensation paid to the pharmacy, by any pharmacy benefits manager, for each covered drug, identified by National Drug Code;

      (3)  for each of those claims, the difference between the amount paid to the pharmacy benefits manager and the amount paid to the pharmacy;

      (4)  the proprietary name, established name or proper name, and the National Drug Code;

      (5)  for each claim for the drug and for each dosage unit of the drug for which a claim was filed, the type of dispensing channel;

      (6)  various information with respect to each drug dispensed, for each type of dispensing channel;

      (7)  the net price per course of treatment or single fill to the plan after rebates received from applicable entities;

      (8)  the total amount of out-of-pocket spending by beneficiaries on the drug;

      (9)  the total net spending on the drug;

      (10)      the total amount received by the plan from any applicable entity in rebates;

      (11)      the total amount received by the pharmacy benefits manager from applicable entities in rebates from those entities:

      (a)  for claims incurred during the reporting period; and

      (b)  that is related to utilization of the drug or spending on the drug; and

      (12)      to the extent feasible, information on the total amount of remuneration for the drug, including copayment assistance or other discounts provided by each drug manufacturer, to the beneficiaries enrolled in the plan.

      The bill requires the reports to contain a list of each therapeutic class, as defined by the department, for which a claim was filed under the health benefits plan during the reporting period, and, with respect to each therapeutic class:

      (1)  the total gross spending on drugs in the class before rebates, price concessions, alternative discounts, or other remuneration from applicable entities;

      (2)  the net spending in the class after rebates, price concessions, alternative discounts, or other remuneration from applicable entities;

      (3)  the total amount received, or expected to be received, by the pharmacy benefits manager, from applicable entities, in rebates from those entities:

      (a)  for claims incurred during the reporting period; and

      (b)  that is related to utilization of drugs or drug spending;

      (4)  the average net spending per 30-day supply and per 90-day supply by the plan with respect to coverage and its beneficiaries, among all drugs within the therapeutic class for which a claim was filed during the reporting period;

      (5)  the number of beneficiaries who filled a prescription for a drug in the class, including the National Drug Code for each drug;

      (6)  if applicable, a description of the formulary tiers and utilization mechanisms employed for drugs in that class; and

      (7)  the total out-of-pocket spending under the plan by beneficiaries, including spending through copayments, coinsurance, and deductibles.

      With respect to any drug for which gross spending under the health benefits plan exceeded $10,000 during the reporting period or, in the case that gross spending under the health benefits plan exceeded $10,000 during the reporting period with respect to fewer than 50 drugs, with respect to the 50 prescription drugs with the highest spending during the reporting period:

      (1)  a list of all other drugs in the same therapeutic class as that drug;

      (2)  if applicable, the rationale for the formulary placement of the drug in that therapeutic category or class, selected from a list of standard rationales established by the department, in consultation with stakeholders; and

      (3)  any change in formulary placement compared to the prior plan year.

      The bill requires a report to contain, in the case that the plan sponsor or pharmacy benefits manager has an affiliated pharmacy or pharmacy under common ownership, including mandatory mail and specialty home delivery programs, retail and mail auto-refill programs, and cost sharing assistance incentives funded by the pharmacy benefits manager:

      (1)  an explanation of any benefit design parameters that encourage or require beneficiaries in the plan to fill prescriptions at mail order, specialty, or retail pharmacies;

      (2)  the percentage of total prescriptions dispensed by the pharmacies to participants or beneficiaries in the plan; and

      (3)  a list of all drugs dispensed by the pharmacies to beneficiaries enrolled in the plan, and certain cost information with respect to each drug dispensed.

      The bill also requires, at the time a report is provided, pharmacy benefits managers to provide to a plan sponsor a summary document for the health benefits plan that includes certain information described in the bill, as specified by the department through guidance, that the department determines useful to plan sponsors for purposes of selecting pharmacy benefit management services, such as an estimated net price to the plan and beneficiary, a cost per claim, the fee structure or reimbursement model, and estimated cost per participant or beneficiary.  The report is to also contain a summary document for plans to provide to beneficiaries, which shall be made available to beneficiaries upon request to the plan, that contains aggregate information as specified by the department through guidance, that the department determines useful to beneficiaries in better understanding the plan or benefits under the plan.

      The bill also provides that, not less than once a year, at the request of the plan sponsor, the pharmacy benefit manager is required to allow for an audit of the pharmacy benefit manager to ensure compliance with all terms and conditions under the contract and the accuracy of information reported pursuant to the bill.