[First Reprint]

ASSEMBLY, No. 4271

STATE OF NEW JERSEY

216th LEGISLATURE

 

INTRODUCED MARCH 9, 2015

 


 

Sponsored by:

Assemblyman  HERB CONAWAY, JR.

District 7 (Burlington)

Assemblyman  DANIEL R. BENSON

District 14 (Mercer and Middlesex)

Assemblywoman  NANCY J. PINKIN

District 18 (Middlesex)

Assemblyman  BENJIE E. WIMBERLY

District 35 (Bergen and Passaic)

 

Co-Sponsored by:

Assemblywomen Jimenez and Angelini

 

 

 

 

SYNOPSIS

     Mandates health benefits coverage for opioid analgesics with abuse-deterrent properties.

 

CURRENT VERSION OF TEXT

     As reported by the Assembly Health and Senior Services Committee on June 1, 2015, with amendments.

  


An Act concerning health benefits coverage for opioid analgesics with abuse-deterrent properties and supplementing various parts of the statutory law.

 

     Be It Enacted by the Senate and General Assembly of the State of New Jersey:

 

     1.    a.  A hospital service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for prescribed abuse-deterrent opioid analgesic drugs, subject to the following requirements:

     (1) If the hospital service corporation provides prescription drug benefits through use of a formulary, 1all1 abuse-deterrent opioid analgesic drugs shall be on the most preferred tier of the formulary;

     (2) Cost sharing for abuse-deterrent opioid analgesic drugs shall not exceed the lowest cost sharing level applied to other prescription drugs; and

     (3) Any prior authorization requirements or other utilization review measures for opioid analgesic drugs shall not require first use of non-abuse-deterrent opioid analgesic drugs in order to access opioid analgesic drugs with abuse-deterrent properties.  Nothing in this subsection shall be construed to prevent the application of prior authorization requirements to abuse-deterrent opioid analgesic drugs, provided that those requirements are also applied to non-abuse-deterrent versions of that opioid.

     b.    The provisions of this section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium.

     c.    As used in this section:

     “Abuse-deterrent opioid analgesic drug” means a brand or generic opioid analgesic drug approved by the United States Food and Drug Administration with abuse-deterrence labeling claims that indicate the drug is expected to result in a meaningful reduction in abuse.

     “Cost sharing” means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements.

     “Opioid analgesic drug” means a drug in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions, whether in immediate release or extended release form, and whether or not combined with other drug substances to form a single drug product or dosage form.

     2.    a.  A medical service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for prescribed abuse-deterrent opioid analgesic drugs, subject to the following requirements:

     (1) If the medical service corporation provides prescription drug benefits through use of a formulary, 1all1 abuse-deterrent opioid analgesic drugs shall be on the most preferred tier of the formulary;

     (2) Cost sharing for abuse-deterrent opioid analgesic drugs shall not exceed the lowest cost sharing level applied to other prescription drugs; and

     (3) Any prior authorization requirements or other utilization review measures for opioid analgesic drugs shall not require first use of non-abuse-deterrent opioid analgesic drugs in order to access opioid analgesic drugs with abuse-deterrent properties.  Nothing in this subsection shall be construed to prevent the application of prior authorization requirements to abuse-deterrent opioid analgesic drugs, provided that those requirements are also applied to non-abuse-deterrent versions of that opioid.

     b.    The provisions of this section shall apply to all medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.

     c.    As used in this section:

     “Abuse-deterrent opioid analgesic drug” means a brand or generic opioid analgesic drug approved by the United States Food and Drug Administration with abuse-deterrence labeling claims that indicate the drug is expected to result in a meaningful reduction in abuse.

     “Cost sharing” means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements.

     “Opioid analgesic drug” means a drug in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions, whether in immediate release or extended release form, and whether or not combined with other drug substances to form a single drug product or dosage form.

 

     3.    a. A health service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for prescribed abuse-deterrent opioid analgesic drugs, subject to the following requirements:

     (1) If the health service corporation provides prescription drug benefits through use of a formulary, 1all1 abuse-deterrent opioid analgesic drugs shall be on the most preferred tier of the formulary;

     (2) Cost sharing for abuse-deterrent opioid analgesic drugs shall not exceed the lowest cost sharing level applied to other prescription drugs; and

     (3) Any prior authorization requirements or other utilization review measures for opioid analgesic drugs shall not require first use of non-abuse-deterrent opioid analgesic drugs in order to access opioid analgesic drugs with abuse-deterrent properties.  Nothing in this subsection shall be construed to prevent the application of prior authorization requirements to abuse-deterrent opioid analgesic drugs, provided that those requirements are also applied to non-abuse-deterrent versions of that opioid.

     b.    The provisions of this section shall apply to all health service corporation contracts in which the health service corporation has reserved the right to change the premium.

     c.    As used in this section:

     “Abuse-deterrent opioid analgesic drug” means a brand or generic opioid analgesic drug approved by the United States Food and Drug Administration with abuse-deterrence labeling claims that indicate the drug is expected to result in a meaningful reduction in abuse.

     “Cost sharing” means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements.

     “Opioid analgesic drug” means a drug in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions, whether in immediate release or extended release form, and whether or not combined with other drug substances to form a single drug product or dosage form.

 

     4.    a.  An individual health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for prescribed abuse-deterrent opioid analgesic drugs, subject to the following requirements:

     (1) If the individual health insurance policy provides prescription drug benefits through use of a formulary, 1all1 abuse-deterrent opioid analgesic drugs shall be on the most preferred tier of the formulary;

     (2) Cost sharing for abuse-deterrent opioid analgesic drugs shall not exceed the lowest cost sharing level applied to other prescription drugs; and

     (3) Any prior authorization requirements or other utilization review measures for opioid analgesic drugs shall not require first use of non-abuse-deterrent opioid analgesic drugs in order to access opioid analgesic drugs with abuse-deterrent properties.  Nothing in this subsection shall be construed to prevent the application of prior authorization requirements to abuse-deterrent opioid analgesic drugs, provided that those requirements are also applied to non-abuse-deterrent versions of that opioid.

     b.    The provisions of this section shall apply to those policies in which the insurer has reserved the right to change the premium.

     c.    As used in this section:

     “Abuse-deterrent opioid analgesic drug” means a brand or generic opioid analgesic drug approved by the United States Food and Drug Administration with abuse-deterrence labeling claims that indicate the drug is expected to result in a meaningful reduction in abuse.

     “Cost sharing” means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements.

     “Opioid analgesic drug” means a drug in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions, whether in immediate release or extended release form, and whether or not combined with other drug substances to form a single drug product or dosage form.

 

     5.    a.  A group health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for prescribed abuse-deterrent opioid analgesic drugs, subject to the following requirements:

     (1) If the group health insurance policy provides prescription drug benefits through use of a formulary, 1all1 abuse-deterrent opioid analgesic drugs shall be on the most preferred tier of the formulary;

     (2) Cost sharing for abuse-deterrent opioid analgesic drugs shall not exceed the lowest cost sharing level applied to other prescription drugs; and

     (3) Any prior authorization requirements or other utilization review measures for opioid analgesic drugs shall not require first use of non-abuse-deterrent opioid analgesic drugs in order to access opioid analgesic drugs with abuse-deterrent properties.  Nothing in this subsection shall be construed to prevent the application of prior authorization requirements to abuse-deterrent opioid analgesic drugs, provided that those requirements are also applied to non-abuse-deterrent versions of that opioid.

     b.    The provisions of this section shall apply to those policies in which the insurer has reserved the right to change the premium.

     c.    As used in this section:

     “Abuse-deterrent opioid analgesic drug” means a brand or generic opioid analgesic drug approved by the United States Food and Drug Administration with abuse-deterrence labeling claims that indicate the drug is expected to result in a meaningful reduction in abuse.

     “Cost sharing” means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements.

     “Opioid analgesic drug” means a drug in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions, whether in immediate release or extended release form, and whether or not combined with other drug substances to form a single drug product or dosage form.

 

     6.    a.  An individual health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for prescribed abuse-deterrent opioid analgesic drugs, subject to the following requirements:

     (1) If the individual health benefits plan provides prescription drug benefits through use of a formulary, 1all1 abuse-deterrent opioid analgesic drugs shall be on the most preferred tier of the formulary;

     (2) Cost sharing for abuse-deterrent opioid analgesic drugs shall not exceed the lowest cost sharing level applied to other prescription drugs; and

     (3) Any prior authorization requirements or other utilization review measures for opioid analgesic drugs shall not require first use of non-abuse-deterrent opioid analgesic drugs in order to access opioid analgesic drugs with abuse-deterrent properties.  Nothing in this subsection shall be construed to prevent the application of prior authorization requirements to abuse-deterrent opioid analgesic drugs, provided that those requirements are also applied to non-abuse-deterrent versions of that opioid.

     b.    The provisions of this section shall apply to all individual health benefits plans in which the carrier has reserved the right to change the premium.

     c.    As used in this section:

     “Abuse-deterrent opioid analgesic drug” means a brand or generic opioid analgesic drug approved by the United States Food and Drug Administration with abuse-deterrence labeling claims that indicate the drug is expected to result in a meaningful reduction in abuse.

     “Cost sharing” means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements.

     “Opioid analgesic drug” means a drug in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions, whether in immediate release or extended release form, and whether or not combined with other drug substances to form a single drug product or dosage form.

 

     7.    a. A small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for prescribed abuse-deterrent opioid analgesic drugs, subject to the following requirements:

     (1) If the small employer health benefits plan provides prescription drug benefits through use of a formulary, 1all1 abuse-deterrent opioid analgesic drugs shall be on the most preferred tier of the formulary;

     (2) Cost sharing for abuse-deterrent opioid analgesic drugs shall not exceed the lowest cost sharing level applied to other prescription drugs; and

     (3) Any prior authorization requirements or other utilization review measures for opioid analgesic drugs shall not require first use of non-abuse-deterrent opioid analgesic drugs in order to access opioid analgesic drugs with abuse-deterrent properties.  Nothing in this subsection shall be construed to prevent the application of prior authorization requirements to abuse-deterrent opioid analgesic drugs, provided that those requirements are also applied to non-abuse-deterrent versions of that opioid.

     b.    The provisions of this section shall apply to all small employer health benefits plans in which the carrier has reserved the right to change the premium.

     c.    As used in this section:

     “Abuse-deterrent opioid analgesic drug” means a brand or generic opioid analgesic drug approved by the United States Food and Drug Administration with abuse-deterrence labeling claims that indicate the drug is expected to result in a meaningful reduction in abuse.

     “Cost sharing” means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements.

     “Opioid analgesic drug” means a drug in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions, whether in immediate release or extended release form, and whether or not combined with other drug substances to form a single drug product or dosage form.

 

     8.    a.  A health maintenance organization contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for prescribed abuse-deterrent opioid analgesic drugs, subject to the following requirements:

     (1) If the health maintenance organization provides prescription drug benefits through use of a formulary, 1all1 abuse-deterrent opioid analgesic drugs shall be on the most preferred tier of the formulary;

     (2) Cost sharing for abuse-deterrent opioid analgesic drugs shall not exceed the lowest cost sharing level applied to other prescription drugs; and

     (3) Any prior authorization requirements or other utilization review measures for opioid analgesic drugs shall not require first use of non-abuse-deterrent opioid analgesic drugs in order to access opioid analgesic drugs with abuse-deterrent properties.  Nothing in this subsection shall be construed to prevent the application of prior authorization requirements to abuse-deterrent opioid analgesic drugs, provided that those requirements are also applied to non-abuse-deterrent versions of that opioid.

     b.    The provisions of this section shall apply to those contracts by health maintenance organizations in which the health maintenance organization has reserved the right to change the premium.

     c.    As used in this section:

     “Abuse-deterrent opioid analgesic drug” means a brand or generic opioid analgesic drug approved by the United States Food and Drug Administration with abuse-deterrence labeling claims that indicate the drug is expected to result in a meaningful reduction in abuse.

     “Cost sharing” means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements.

     “Opioid analgesic drug” means a drug in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions, whether in immediate release or extended release form, and whether or not combined with other drug substances to form a single drug product or dosage form.

 

     9.    a.  The State Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits shall provide coverage for prescribed abuse-deterrent opioid analgesic drugs, subject to the following requirements:

     (1) If the contract provides prescription drug benefits through use of a formulary, 1all1 abuse-deterrent opioid analgesic drugs shall be on the most preferred tier of the formulary;

     (2) Cost sharing for abuse-deterrent opioid analgesic drugs shall not exceed the lowest cost sharing level applied to other prescription drugs; and

     (3) Any prior authorization requirements or other utilization review measures for opioid analgesic drugs shall not require first use of non-abuse-deterrent opioid analgesic drugs in order to access opioid analgesic drugs with abuse-deterrent properties.  Nothing in this subsection shall be construed to prevent the application of prior authorization requirements to abuse-deterrent opioid analgesic drugs, provided that those requirements are also applied to non-abuse-deterrent versions of that opioid.

     b.    As used in this section:

     “Abuse-deterrent opioid analgesic drug” means a brand or generic opioid analgesic drug approved by the United States Food and Drug Administration with abuse-deterrence labeling claims that indicate the drug is expected to result in a meaningful reduction in abuse.

     “Cost sharing” means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements.

     “Opioid analgesic drug” means a drug in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions, whether in immediate release or extended release form, and whether or not combined with other drug substances to form a single drug product or dosage form.

 

     10.  a.  The School Employees’ Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits shall provide coverage for prescribed abuse-deterrent opioid analgesic drugs, subject to the following requirements:

     (1)   If the contract provides prescription drug benefits through use of a formulary, 1all1 abuse-deterrent opioid analgesic drugs shall be on the most preferred tier of the formulary;

     (2)   Cost sharing for abuse-deterrent opioid analgesic drugs shall not exceed the lowest cost sharing level applied to other prescription drugs; and

     (3)   Any prior authorization requirements or other utilization review measures for opioid analgesic drugs shall not require first use of non-abuse-deterrent opioid analgesic drugs in order to access opioid analgesic drugs with abuse-deterrent properties.  Nothing in this subsection shall be construed to prevent the application of prior authorization requirements to abuse-deterrent opioid analgesic drugs, provided that those requirements are also applied to non-abuse-deterrent versions of that opioid.

     b.    As used in this section:

     “Abuse-deterrent opioid analgesic drug” means a brand or generic opioid analgesic drug approved by the United States Food and Drug Administration with abuse-deterrence labeling claims that indicate the drug is expected to result in a meaningful reduction in abuse.

     “Cost sharing” means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements.

     “Opioid analgesic drug” means a drug in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions, whether in immediate release or extended release form, and whether or not combined with other drug substances to form a single drug product or dosage form.

 

     11.  This act shall take effect on the 90th day after enactment.