Bill > S1047

Introduced Session

This bill regulates certain practices of pharmacy benefits managers and health insurance carriers. Under the bill, a pharmacy benefits manager will be prohibited from the practice of steering, which, for the purpose of this bill, 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 benefit manager or carrier has an ownership interest, and includes but is not limited to retail, mail-order, or specialty pharmacies. On March 1 of each year, a pharmacy benefits manager or carrier that utilizes a contracted pharmacy benefits manager will be required to provide a letter to the commissioner attesting as to whether or not, in the previous calendar year, it engaged in the practice of steering. The pharmacy benefits manager will also submit to the commissioner, in a form and manner specified by the commissioner, data detailing all prescription drug claims it administered for covered persons on behalf of each health plan client and any other data the commissioner deems necessary to evaluate whether a pharmacy benefits manager is engaged in the practice of steering. This data will be confidential and not be subject to the "Open Public Records Act;" provided, however, that the commissioner prepare an aggregate report reflecting the total number of prescriptions administered by the reporting pharmacy benefits manager on behalf of all health plans in the State along with the total sum due to the State. The department will have access to all confidential data collected by the Commissioner for audit purposes. Under the bill, a pharmacy benefits manager that engages in the practice of steering or imposing point-of-sale fees or retroactive fees will be subject to a surcharge payable to the State of 10 percent on the aggregate dollar amount it reimbursed pharmacies in the previous calendar year for prescription drugs. Any other person operating a health plan and licensed under this title whose contracted pharmacy benefits manager engages in the practice of steering in connection with its health plans will be subject to a surcharge payable to the State of 10 percent on the aggregate dollar amount its pharmacy benefits manager reimbursed pharmacies on its behalf in the previous calendar year for prescription drugs. The bill also provides that a pharmacy benefits manager will be proscribed from, among other provisions: (1) prohibiting a pharmacist or pharmacy from providing a covered person information on the amount of the covered person's cost sharing for the covered person's prescription drug and the clinical efficacy of a more affordable alternative drug if one is available; (2) 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; or (3) 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 reimbursement, formulary compliance, pharmacy care, or utilization review. The bill further provides that a health insurance carrier or pharmacy benefits manager will: (1) be prohibited from requiring pharmacy accreditation standards or recertification requirements to participate in a network which is inconsistent with, more stringent than, or in addition to, the federal and State requirements for a pharmacy in this State; and (2) suspend denials based on health care provider credentialing requirements. Any credentialing determination shall be issued within 45 days after receipt by the health insurance carrier of a universal physician application credentialing application or a complete New Jersey physician recredentialing application. The bill additionally provides that a health insurance carrier or pharmacy benefits manager will produce a report every four months, which will be provided to the commissioner and published by the pharmacy benefits manager on a website available to the public for no less than 24 months, of all drugs appearing on the national average drug acquisition cost list reimbursed 10 percent above or below the national average drug acquisition cost, as well as all drugs reimbursed 10 percent or above the national average drug acquisition cost. Under the bill, a pharmacy benefits manager will not be allowed to engage in the practice of medicine, unless a physician employed or contracted by a pharmacy benefits manager is advising on or making determinations specific to a covered person in connection with a prior authorization or step therapy appeal or determination review and is able to meet certain requirements. Finally, the bill provides that a pharmacy benefits manager will, among other related provisions: (1) not require covered persons to use a mail-order pharmaceutical distributor, including a mail-order pharmacy; or (2) offer a health insurance carrier the ability to receive 100 percent of all rebates it receives from pharmaceutical manufacturers. In addition, a pharmacy benefits manager shall report annually to each client, which shall include but not be limited to insurers, payors, health plans, and the department the aggregate amount of all rebates and other payments that a pharmacy benefits manager received from a pharmaceutical manufacturer in connection with claims, if administered on behalf of the client and the aggregate amount of such rebates a pharmacy benefits manager received from a pharmaceutical manufacturer did not pass through to the client health plan.

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Vin Gopal (D)*,  Linda Greenstein (D)*,  Shirley Turner (D), 

Introduced in the Senate, Referred to Senate Commerce Committee (on 01/09/2024)

Official Document