Bill > A1825

This bill establishes comprehensive guidelines for step therapy protocols in health insurance programs, specifically targeting the State Health Benefits Program (SHBP), School Employees Health Benefits Program (SEHBP), and Medicaid. Step therapy is a process where patients are required to try one or more prescription drugs before insurance will cover a drug selected by their healthcare provider. The bill mandates that step therapy protocols must be based on high-quality, scientifically developed clinical practice guidelines created by multidisciplinary expert panels that minimize conflicts of interest and rely on objective data. Healthcare providers can request exceptions to step therapy protocols if the required drug could cause harm, is expected to be ineffective, or if previous formulary drugs have been unsuccessful. The bill requires insurance carriers to provide a clear, accessible process for requesting these exceptions, with decisions to be made within 24 hours for urgent requests and 72 hours for non-urgent requests. Carriers must also make their clinical review criteria publicly available and publish statistics about step therapy exception approvals and denials. The goal is to balance cost control with patient safety, ensuring that treatment decisions prioritize individual patient needs while maintaining transparency in the drug prescription process. The provisions will take effect on January 1, 2026, applying to all new and renewed insurance contracts.

Budget and Finance, Business and Industry, Health and Social Services

https://www.njleg.state.nj.us/bill-search/2024/A1825