ASSEMBLY FINANCIAL INSTITUTIONS AND INSURANCE COMMITTEE
STATEMENT TO
ASSEMBLY, No. 2431
STATE OF NEW JERSEY
DATED: JUNE 11, 2018
The Assembly Financial Institutions and Insurance Committee reports favorably Assembly Bill No. 2431.
This bill requires certain health insurers, under certain policies or contracts that provide coverage for prescription drugs, to place limitations on covered persons’ cost sharing for prescription drugs. The bill’s provisions apply to the following insurers and programs that provide coverage for prescription drugs under a policy or contract: health, hospital and medical service corporations; commercial individual and group health insurers; health maintenance organizations; health benefits plans issued pursuant to the New Jersey Individual Health Coverage and Small Employer Health Benefits Programs; the State Health Benefits Program (SHBP) and the School Employees’ Health Benefits Program (SEHBP).
Unless the plan or contract is required to provide bronze level coverage or is a catastrophic plan under the federal Affordable Care Act, the bill requires insurers to ensure that plans limit a covered person’s out-of-pocket financial responsibility, including any copayment or coinsurance, for prescription drugs, including specialty drugs, to no more than $100 per month for each prescription drug for up to a 30-day supply of any single drug. If the plan or contract is required to provide bronze level coverage, as defined in 45 C.F.R. s.156.140, the plan shall ensure that any required enrollee cost-sharing, including any copayment or coinsurance, does not exceed $200 per month for each prescription drug for up to a 30-day supply of any single drug. In the case of a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, it is exempt from these requirements.
In the case of high-deductible plans, these cost sharing limits apply at any point in the benefit design, including before and after any applicable deductible is reached. For prescription drug benefits offered in conjunction with a high-deductible health plan, the plan shall not provide prescription drug benefits until the expenditures applicable to the deductible under the plan have met the amount of the minimum annual deductibles in effect for self-only and family coverage under section 223(c)(2)(A)(i) of the federal Internal Revenue Code (26 U.S.C. 223(c)(2)(A)(i)) for self-only and family coverage, respectively. Once the foregoing expenditure amount has been met under the plan, coverage for prescription drug benefits shall begin, and the limit on out-of-pocket expenditures for prescription drug benefits would be as specified in the bill.
The bill also requires the plans to implement an exceptions process that allows enrollees to request an exception to any formulary, which exception shall permit a nonformulary drug to be deemed covered under the formulary if the prescribing physician determines that the formulary drug for treatment of the same condition either would not be as effective for the enrollee or would have adverse effects for the enrollee, or both. If an enrollee is denied such an exception, that denial is deemed an adverse determination that will be subject to appeal.