Bill > A999

Introduced Session

This bill places certain restrictions on health insurance carriers and pharmacy benefits managers relating to the switching of drugs and medication, and step therapy and fail first practices. The bill requires that a health insurance carrier that offers a health benefits plan that covers prescription drugs shall not limit, reduce, or deny coverage for any drugs currently in use by a person covered under the plan, except in certain situations. The bill also places certain restrictions and disclosure requirements on therapeutic substitutions of medications. The bill also places certain requirements on carriers and pharmacy benefits managers in situations in which a covered person's prescribed medication is switched to a medication other than that originally prescribed by the prescriber. The bill requires a switch communication to be provided, which must contain certain disclosures to covered persons and health benefit plan sponsors, including the right of a covered person to file an appeal with respect to the switch. The Department of Banking and Insurance is required to create one form for carriers and pharmacy benefit managers to use in providing switch communications to covered persons, prescribers, carriers, and plan sponsors, and to adopt certain rules and regulations governing switch communications, as set forth in the bill. The bill also provides that, notwithstanding any other law or contract to the contrary, whenever a carrier that offers a health benefits plan restricts coverage for a medication for the treatment of any medical condition through the use of a step therapy or fail first protocol, the carrier shall provide the prescriber access to a clear and convenient process, at no charge to the prescriber or covered person, that the prescriber may use to override the coverage restriction. The prescriber may use the process, and the carrier shall provide coverage for the medication prescribed by the prescriber, if: (1) the prescriber, in the prescriber's professional judgment, determines, at any time, that the drug preferred by the carrier as part of a step therapy or fail first protocol has been ineffective in the treatment of the covered person's disease or medical condition or has caused an adverse reaction or other harm to the covered person; or (2) based on sound clinical evidence and medical and scientific evidence, the prescriber, in the prescriber's professional judgment, determines that: · the drug preferred by the carrier or the pharmacy benefits manager is expected to be ineffective based on the known relevant physical or mental characteristics of the covered person and known characteristics of the drug regimen, and is likely to adversely affect patient compliance; or · the preferred drug is expected to cause an adverse reaction or other harm to the covered person. The bill specifies that the duration of any step therapy or fail first protocol shall not be longer than the period deemed necessary by the prescriber to determine the treatment's clinical effectiveness. For medications with no generic equivalent and for which the prescriber in their clinical judgment feels that no appropriate therapeutic alternative is available, a carrier or pharmacy benefits manager shall provide access to U.S. Food and Drug Administration (FDA) labeled medications without restriction to treat the medical conditions for which FDA labeled mediation is available. Finally, the bill provides that the Commissioner of Banking and Insurance, in consultation with the Commissioner of Health, shall adopt, pursuant to the "Administrative Procedure Act'" P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations, including any penalty provisions the commissioners deem necessary, to effectuate the purposes of the bill.

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Kevin Rooney (R)*, 

Introduced, Referred to Assembly Financial Institutions and Insurance Committee (on 01/09/2018)