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  • NJ A3001
  • Restricts health insurers from limiting access to pain medication.
In Committee
Crossed OverPassedSignedDead/Failed/Vetoed
2016-2017 Regular Session
This bill requires certain health insurers, under every policy or contract that provides coverage for outpatient prescription drugs, to provide coverage for prescription drugs used to treat pain in accordance with its provisions. The bill's provisions apply to the following insurers and programs that provide coverage for outpatient prescription drugs under a policy or contract: health, hospital and medical service corporations; commercial individual and group health insurers; health maintenance organizations; health benefits plans issued pursuant to the New Jersey Individual Health Coverage and Small Employer Health Benefits Programs; the State Health Benefits Program (SHBP) and the School Employees' Health Benefits Program (SEHBP). The bill provides that if the insurer or program, in its policy or contract, restricts coverage for medications for the treatment of pain pursuant to a step therapy or fail-first protocol, the duration of the step therapy or fail-first protocol is to be determined by the prescriber. The insurer or program may not require a covered person to try and fail on more than one pain medication before providing coverage for the medication that has been prescribed. Once a covered person has tried and failed on one pain medication, the insurer or program will no longer require prior authorization for coverage of pain medication for the person, and the prescriber may write a prescription for the appropriate pain medication. The prescriber is to note in the covered person's medical record that the person tried and failed on the step therapy or fail-first protocol, and this is to suffice as prior authorization from the insurer or program. If a prescriber notes on the prescription that the step therapy or fail-first protocols have been met, a pharmacist may process the prescription without additional communication with the insurer or program. The bill provides that nothing in its provisions is to be construed to prohibit an insurer or program from charging a covered person a copayment or deductible for prescription drug benefits or from setting forth, in the policy or contract, limitations on maximum coverage of prescription drug benefits as permitted under law or regulation, and further provides that nothing in the bill is to be construed to require coverage of prescription drugs that are not in the drug formulary of the insurer or program or to prohibit generic drug substitutions pursuant to law.
Health and Senior Services
Introduced, Referred to Assembly Health and Senior Services Committee  (on 2/16/2016)
Date Chamber Action Description
2/16/2016 A Introduced, Referred to Assembly Health and Senior Services Committee
Date Motion Yea Nay Other
None specified