Bill Text: NJ A5914 | 2020-2021 | Regular Session | Introduced
Bill Title: Requires health insurance carriers to utilize real time benefit tool for prescription drugs.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Introduced - Dead) 2021-06-21 - Introduced, Referred to Assembly Financial Institutions and Insurance Committee [A5914 Detail]
Download: New_Jersey-2020-A5914-Introduced.html
Sponsored by:
Assemblyman DANIEL R. BENSON
District 14 (Mercer and Middlesex)
Assemblyman RAJ MUKHERJI
District 33 (Hudson)
SYNOPSIS
Requires health insurance carriers to utilize real time benefit tool for prescription drugs.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning health insurance carriers and prescription drugs and supplementing P.L.1997, c.192 (C.26:2S-1 et seq.).
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. This act shall be known and may be cited as the "Patient Rx Information and Choice Expansion (PRICE) Act."
2. The Legislature finds and declares:
The patient out-of-pocket cost burden for medically necessary treatments can negatively impact the likelihood of treatment initiation and adherence, and increases overall drug abandonment rates;
High deductible plans now account for almost 50 percent of employer covered lives, which causes patients' cost sharing for medically necessary treatments to rise, and increases financial toxicity and non-adherence rates;
Patient non-adherence to prescribed medications is associated with poor clinical outcomes, progression of disease, and an estimated burden of billions per year in avoidable direct health care costs;
Between $100 and $300 billion of avoidable health care costs have been attributed to non-adherence in the US annually, representing 3 to 10 percent of total US health care costs;
The Congressional Budget Office recognizes that increasing the number of prescriptions filled decreases spending on other medical services;
The Centers for Medicare and Medicaid Services have found that health plans and entities acting on behalf of those plans may have misaligned incentives that drive utilization of higher cost medicines and hinder patient choice, to lower cost options due to lack of price transparency;
Prescription price transparency is critical to lowering overall drug costs and patient out-of-pocket costs and supports improved medication adherence.
Providers and patients should make treatment choices based on what is best for the individual patient;
At a time when patients are being required to pay more and more out-of-pocket for health care, they need access to real-time, patient-specific information via means of their choosing;
Patients need to be able to understand their drug benefit coverage and payment considerations for drugs on and off a plan's formulary, including lower cost clinical and therapeutic alternatives;
The COVID-19 pandemic has demonstrated that health care professionals may not always be available to assist patients with prescription access and patients need access to tools and resources at all points in the prescription process that empower them and give them up-to-date prescription pricing options; and
This act seeks to provide real-time, patient specific, prescription drug out-of-pocket cost information at the point of prescribing thereby providing patients with transparency and an understanding of what their out-of-pocket costs will be for their medically necessary medications.
3. a. A carrier, or an entity acting on a carrier's behalf, shall electronically provide to any policyholder a real-time benefit tool that provides the information regarding patient prescription price transparency and patient access to prescribed medication required pursuant to this act.
b. A real-time benefit tool shall provide a policyholder information concerning:
(1) patient-specific eligibility;
(2) patient-specific prescription cost and benefit data, including applicable formulary, benefit, coverage and cost-sharing data for the prescribed drug and clinically-appropriate alternatives, when appropriate;
(3) patient-specific cost-sharing that describes variance in cost-sharing based on the pharmacy dispensing the prescribed drug or its alternatives, and in relation to the patient's benefit;
(4) lower cost clinically-appropriate treatment alternatives; and
(5) applicable utilization management requirements, such as prior authorization.
c. A real-time benefit tool shall comply with technical standards adopted by an organization accredited by the American National Standards Institute.
d. A carrier shall not prohibit a real-time benefit tool from displaying cost, benefit and coverage information that reflects other choices, such as cash price, patient assistance and support programs, and the cost available at the patient's pharmacy of choice.
e. Nothing in this section shall require a carrier to furnish a unique real-time benefit tool. A carrier may meet the requirements of this section by transmitting data through an intermediary, real-time network, switch, or other appropriate entity.
4. a. Nothing in this act shall interfere with patient choice and a health care professional's ability to convey the full range of prescription drug cost options to a patient. A carrier or an entity acting on a carrier's behalf, shall not restrict a health care professional from communicating to the patient prescription cost options.
b. Nothing in this act shall supersede or preempt the provisions of P.L.1989, c.19 (C.45:9-22.4 et seq.), which prohibits a physician from referring patients to health care services in which the physician or physician's family maintains a financial interest.
c. A real-time benefit tool shall safe guard against steering patients to plan preferred drugs or pharmacies and providers shall not utilize a real-time benefit tool to steer patients to any specific pharmacies.
5. This act shall take effect on 120th day next following enactment, and shall apply to health insurance policies issued or renewed after that date.
STATEMENT
This bill requires health insurance carriers to utilize a real time benefit tool for prescription drugs.
Specifically, the bill requires carriers, or entities acting on their behalf, to electronically provide to any policyholder a real-time benefit tool that provides the information regarding patient prescription price transparency and patient access to prescribed medication.
The bill provides that a real-time benefit tool is required to provide a policyholder with information concerning:
(1) patient-specific eligibility;
(2) patient-specific prescription cost and benefit data;
(3) patient-specific cost-sharing;
(4) information regarding lower cost clinically-appropriate treatment alternatives; and
(5) applicable utilization management requirements, such as prior authorization.
The bill requires real-time benefit tools to comply with technical standards adopted by an organization accredited by the American National Standards Institute.
The bill provides that carriers may not prohibit a real-time benefit tool from displaying cost, benefit and coverage information that reflects other choices, such as cash price, patient assistance and support programs, and the cost available at the patient's pharmacy of choice.
Nothing in the bill requires a carrier to furnish a unique real-time benefit tool. A carrier may meet the requirements of the bill by transmitting data through an intermediary, real-time network, switch, or other appropriate entity.
The bill provides that it does not interfere with patient choice or a health care professional's ability to convey the full range of prescription drug cost options to a patient. A carrier or an entity acting on a carrier's behalf, shall not restrict a health care professional from communicating to the patient prescription cost options.
Nothing in the bill supersedes or preempts the provisions of current law, which prohibit physicians from referring patients to health care services in which they maintain a financial interest.
A real-time benefit tool is required to safe guard against steering patients to plan preferred drugs or pharmacies and providers may not utilize a real-time benefit tool to steer patients to any specific pharmacies.
