Bill Text: NJ A4682 | 2024-2025 | Regular Session | Introduced
Bill Title: Prohibits health insurance carriers from denying coverage of nonopioid prescription drugs in favor of opioid prescription drugs.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced) 2024-09-12 - Introduced, Referred to Assembly Financial Institutions and Insurance Committee [A4682 Detail]
Download: New_Jersey-2024-A4682-Introduced.html
Sponsored by:
Assemblyman ANTHONY S. VERRELLI
District 15 (Hunterdon and Mercer)
SYNOPSIS
Prohibits health insurance carriers from denying coverage of nonopioid prescription drugs in favor of opioid prescription drugs.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning nonopioid medication 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. Notwithstanding any law, rule, or regulation to the contrary, when a licensed health care provider prescribes a nonopioid medication to a covered person for the treatment of acute pain, it shall be unlawful for a carrier to deny coverage of a nonopioid prescription drug:
(1) in favor of an opioid prescription drug; or
(2) to require a covered person to try an opioid prescription drug prior to approving the use of a nonopioid prescription drug.
b. If a carrier establishes and maintains a drug formulary, the carrier shall ensure that a nonopioid drug approved by the United States Food and Drug Administration for the treatment or management of pain will not be disadvantaged or discouraged, with respect to coverage or cost-sharing, relative to any opioid or narcotic drug for the treatment or management of pain on the formulary of the carrier, where impermissible disadvantaging or discouragement includes, without limitation:
(1) imposing more restrictive coverage criteria on any nonopioid drug than the least restrictive criteria imposed on an opioid or narcotic drug;
(2) establishing more restrictive or more extensive utilization controls, including, but not limited to, more restrictive or more extensive prior authorization or step therapy requirements, for nonopioid drugs than the least restrictive or extensive utilization controls applicable to an opioid or narcotic drug; or
(3) if the carrier maintains a formulary grouped into tiers for the purposes of determining cost-sharing, placing any nonopioid drug on a tier that requires a cost-sharing responsibility that exceeds the lowest cost-sharing responsibility required for an opioid or narcotic drug on the formulary.
c. Subsection b. of this section shall not preclude:
(1) opioid drugs from being preferred over other opioid drugs; or
(2) nonopioid drugs from being preferred over other nonopioid drugs.
2. a. Notwithstanding any law, rule, or regulation to the contrary, the State Health Benefits Commission shall ensure that in every contract providing hospital or medical expense benefits that is purchased by the commission on or after the effective date of this act, a nonopioid medication prescribed to a covered person for the treatment of acute pain shall not be denied coverage:
(1) in favor of an opioid prescription drug; or
(2) so that a covered person be required to try an opioid prescription drug prior to approving the use of a nonopioid prescription drug.
b. For contracts that use and maintain a drug formulary, it shall be required that a nonopioid drug approved by the United States Food and Drug Administration for the treatment or management of pain will not be disadvantaged or discouraged, with respect to coverage or cost-sharing, relative to any opioid or narcotic drug for the treatment or management of pain on the formulary. Impermissible disadvantaging or discouragement includes, without limitation:
(1) imposing more restrictive coverage criteria on any nonopioid drug than the least restrictive criteria imposed on an opioid or narcotic drug;
(2) establishing more restrictive or more extensive utilization controls, including, but not limited to, more restrictive or more extensive prior authorization or step therapy requirements, for nonopioid drugs than the least restrictive or extensive utilization controls applicable to an opioid or narcotic drug; or
(3) if the contract uses and maintains a formulary grouped into tiers for the purposes of determining cost-sharing, placing any nonopioid drug on a tier that requires a cost-sharing responsibility that exceeds the lowest cost-sharing responsibility required for an opioid or narcotic drug on the formulary.
c. Subsection b. of this section shall not preclude:
(1) opioid drugs from being preferred over other opioid drugs; or
(2) nonopioid drugs from being preferred over other nonopioid drugs.
3. a. Notwithstanding any law, rule, or regulation to the contrary, the School Employees' Health Benefits Commission shall ensure that in every contract providing hospital or medical expense benefits, which is purchased by the commission on or after the effective date of this act, a nonopioid medication prescribed to a covered person for the treatment of acute pain shall not be denied coverage:
(1) in favor of an opioid prescription drug; or
(2) so that a covered person be required to try an opioid prescription drug prior to approving the use of a nonopioid prescription drug.
b. For contracts that use and maintain a drug formulary, it shall be required that a nonopioid drug approved by the United States Food and Drug Administration for the treatment or management of pain will not be disadvantaged or discouraged, with respect to coverage or cost-sharing, relative to any opioid or narcotic drug for the treatment or management of pain on the formulary, where impermissible disadvantaging or discouragement includes, without limitation:
(1) imposing more restrictive coverage criteria on any nonopioid drug than the least restrictive criteria imposed on an opioid or narcotic drug;
(2) establishing more restrictive or more extensive utilization controls, including, but not limited to, more restrictive or more extensive prior authorization or step therapy requirements, for nonopioid drugs than the least restrictive or extensive utilization controls applicable to an opioid or narcotic drug; or
(3) if the contract uses and maintains a formulary grouped into tiers for the purposes of determining cost-sharing, placing any nonopioid drug on a tier that requires a cost-sharing responsibility that exceeds the lowest cost-sharing responsibility required for an opioid or narcotic drug on the formulary.
c. Subsection b. of this section shall not preclude:
(1) opioid drugs from being preferred over other opioid drugs; or
(2) nonopioid drugs from being preferred over other nonopioid drugs.
4. a. Notwithstanding any State law, rule, or regulation to the contrary, whenever a licensed health care provider prescribes a nonopioid medication for the treatment of acute pain to persons served under the Medicaid program, established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), the Department of Human Services shall not deny coverage of the nonopioid prescription drug:
(1) in favor of an opioid prescription drug; or
(2) so that a covered person be required to try an opioid prescription drug prior to approving use of a nonopioid prescription drug.
b. In establishing and maintaining a preferred drug list, the Department of Human Services shall ensure that nonopioid drugs on the list, and approved by the United States Food and Drug Administration, for the treatment or management of pain shall not be disadvantaged or discouraged with respect to coverage relative to any opioid or narcotic drug for the treatment or management of pain.
5. This act shall take effect on January 1, 2026 and shall apply to policies, plans, and contracts that are delivered, issued, executed, or renewed on or after that date.
STATEMENT
This bill makes it unlawful when a licensed health care provider prescribes a nonopioid medication to a person covered by a health insurance carrier for the treatment of acute pain and the carrier denies coverage of a nonopioid prescription drug: (1) in favor of an opioid prescription drug; or (2) to require a covered person to try an opioid prescription drug prior to approving the use of a nonopioid prescription drug. "Carrier" is defined in the bill to mean an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State.
Under the bill, a carrier that establishes and maintains a drug formulary is to ensure that a nonopioid drug approved by the United States Food and Drug Administration for the treatment or management of pain will not be disadvantaged or discouraged, with respect to coverage or cost-sharing, relative to any opioid or narcotic drug for the treatment or management of pain on the formulary of the carrier under various circumstances. It is not prohibited in the bill for an opioid drug to be preferred over another opioid drug or for a nonopioid drug to be preferred over another nonopioid drug.
The provisions of the bill prohibiting denial of a nonopioid prescription drug are also incorporated into the laws governing the required coverage for contracts negotiated by the State Health Benefits Commission and the School Employees' Health Benefits Commission, and in the law overseeing Medicaid.
