Bill > A1590

Introduced Session

This bill requires health insurance carriers to provide continued coverage of prescription drugs for covered persons diagnosed with a complex or chronic medical condition or a rare disease during a coverage appeal based on medical necessity. The bill defines "complex or chronic medical condition" as a physical, behavioral, or developmental condition that does not have a known cure or that can be severely debilitating or fatal if left untreated or undertreated. "Rare disease" is defined as any disease or condition that affects less than 200,000 persons in the United States. The bill requires hospital, medical and health service corporations, commercial insurers, health maintenance organizations, health benefits plans issued pursuant to the New Jersey Individual Health Coverage and Small Employer Health Benefits Programs, prepaid prescription service organizations, and plans provided by the State Health Benefits Commission and the School Employees' Health Benefits Commission to continue to provide coverage for a drug for a covered person with a complex or chronic medical condition or a rare disease, if the drug was previously covered by the policy or contract, while an appeal is at any stage of the appeals process in situations in which a covered person appeals a denial of coverage for the drug based on medical necessity, except under certain circumstances. With respect to a drug for a covered person with a complex or chronic medical condition or a rare disease in situations in which a covered person appeals a denial of coverage for the drug based on medical necessity, while the appeal is in any stage of the appeals process, the bill provides the provisions of the policy or contract shall not apply so as to: (1) set forth limitations on maximum coverage of prescription drug benefits; (2) subject the covered person to increased out-of-pocket costs; or (3) move a drug for a covered person to a more restrictive tier, if the policy or contract uses a formulary with tiers. The bill further provides that a policy or contract may only deny coverage during the appeals process for a drug for a covered person with a complex or chronic medical condition or a rare disease if: (1) the prescribing provider has discontinued prescription of the drug for the covered person; (2) the United States Food and Drug Administration has issued a notice, guidance, warning, announcement, or any other statement about the drug which calls into question the clinical safety of the drug; or (3) the manufacturer of the drug has notified the United States Food and Drug Administration of any manufacturing discontinuance or potential discontinuance as required by 21 U.S.C.s.356c.

Committee Categories

Andrea Katz (D)*,  Verlina Reynolds-Jackson (D),  Gary Schaer (D), 

Introduced, Referred to Assembly Financial Institutions and Insurance Committee (on 01/09/2024)

Official Document