Sponsored by:
Senator LINDA R. GREENSTEIN
District 14 (Mercer and Middlesex)
Senator VIN GOPAL
District 11 (Monmouth)
SYNOPSIS
Regulates certain practices of pharmacy benefits managers and health insurance carriers.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning pharmacy benefits managers and health insurance carriers and supplementing P.L.2015, c.179 (C.17B:27F-1 et seq.).
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. The Legislature finds and declares that:
a. The practice of steering by a pharmacy benefits manager represents a conflict of interest;
b. These practices have resulted in harm, including increasing drug prices, overcharging covered persons and carriers, restricting or underpaying covered persons choice of pharmacies and fragmenting and creating barriers to care, particularly in rural New Jersey and for patients battling life-threatening illnesses and chronic diseases; and
c. Imposing a surcharge on pharmacy benefits managers that engage in steering in this State may encourage carriers to use pharmacy benefits managers committed to refraining from steering practices.
2. As used in this act:
Commissioner means the Commissioner of Banking and Insurance.
Credentialing means the process of assessing and validating the qualifications of a health care provider including, but not limited to, an evaluation of licensure status, education, training, experience, competence and professional judgement.
Department means the Department of Banking and Insurance.
Health care provider" means an individual, which, acting within the scope of its licensure or certification, provides health care services, and includes, but is not limited to: a physician, dentist, nurse, pharmacist or other health care professional and whose professional practice is regulated pursuant to Title 45 of the Revised Statutes. Health care provider shall also mean a hospital or other health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.)
Medicaid means the program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.).
National average drug acquisition cost means the monthly survey of retail pharmacies conducted by the federal Centers for Medicare and Medicaid Services to determine average acquisition cost for Medicaid covered outpatient drugs.
Steering means a practice
employed by a pharmacy benefit manager or health carrier that channels a
prescription to an affiliated pharmacy, or pharmacy in which a pharmacy benefits
manager or carrier has an ownership interest, and includes but is not limited
to retail, mail-order, or specialty pharmacies.
3. A pharmacy benefits manager shall:
a. not require a covered person to use a mail-order pharmaceutical distributor, including a mail-order pharmacy;
b. offer a health benefits plan the option of charging such health plan the same price for a prescription drug as it pays a pharmacy for the prescription drug; provided, however, that a pharmacy benefits manager shall charge a health benefits plan, the same price for a prescription drug as it pays a pharmacy for the prescription drug;
c. report in the aggregate to a health benefits plan the difference between the amount a pharmacy benefits manager reimbursed a pharmacy and the amount a pharmacy benefits manager charged a health benefits plan; and
d. when calculating a covered person's contribution to any out-of-pocket maximum, deductible, or copayment responsibility, include any amount paid by the covered person or paid on his or her behalf through a third-party payment, financial assistance, discount, or product voucher for a prescription drug that does not have a generic equivalent or that has a generic equivalent but was obtained through prior authorization, a step therapy protocol, or the carriers exceptions and appeals process. Nothing in this subsection shall be construed to require that a pharmacy benefits manager accept a third-party payment, financial assistance, discount, or product voucher submitted on behalf of a covered person.
4. A pharmacy benefits manager shall be proscribed from:
a. prohibiting a pharmacist or pharmacy from providing a covered person information on the amount of the covered persons cost sharing for the covered persons prescription drug and the clinical efficacy of a more affordable alternative drug if one is available;
b. charging or collecting from a covered person a copayment that exceeds the total submitted charges by the network pharmacy for which the pharmacy is paid;
c. transferring or sharing records relative to prescription information containing patient-identifiable and prescriber-identifiable data to an affiliated pharmacy for any commercial purpose; provided, however, that nothing shall be construed to prohibit the exchange of prescription information between a pharmacy benefits manager and an affiliated pharmacy for the limited purposes of pharmacy re