Bill Text: NJ S2019 | 2024-2025 | Regular Session | Amended
Bill Title: Authorizes pharmacists to dispense HIV prophylaxis without individual prescription under certain circumstances; mandates prescription benefits coverage.
Spectrum: Partisan Bill (Democrat 5-0)
Status: (Introduced) 2024-12-09 - Referred to Senate Budget and Appropriations Committee [S2019 Detail]
Download: New_Jersey-2024-S2019-Amended.html
SENATE, No. 2019
STATE OF NEW JERSEY
221st LEGISLATURE
PRE-FILED FOR INTRODUCTION IN THE 2024 SESSION
Sponsored by:
Senator VIN GOPAL
District 11 (Monmouth)
Senator JOHN F. MCKEON
District 27 (Essex and Passaic)
Co-Sponsored by:
Senator Turner
SYNOPSIS
Authorizes pharmacists to dispense HIV prophylaxis without individual prescription under certain circumstances; mandates prescription benefits coverage.
CURRENT VERSION OF TEXT
As reported by the Senate Health, Human Services and Senior Citizens Committee on December 9, 2024, with amendments.
An Act concerning pharmacists and supplementing Titles 17, 26, 45, and 52 of the Revised Statutes and Title 17B of the New Jersey Statutes.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. As used in this act:
"CDC PEP guidelines" means the "Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV - United States, 2016," or any subsequent guidelines, published by the federal Centers for Disease Control and Prevention.
"CDC 1[PReP] PrEP1 guidelines" means the "2017 Preexposure Prophylaxis for the Prevention of HIV Infection in the United States - 2017 Update: A Clinical Practice Guideline," or any subsequent guidelines, published by the federal Centers for Disease Control and Prevention.
"HIV" means the human immunodeficiency virus.
"HIV preexposure prophylaxis" means 1[a fixed-dose combination of tenofovir disoproxil fumarate (TDF) (300 mg) with emtricitabine (FTC) (200 mg), or another] any1 drug or drug combination 1[determined by the State Board of Pharmacy to meet]1 authorized or approved by the United States Food and Drug Administration for the prevention of HIV that meets1 the 1[same]1 clinical 1[eligibility]1 recommendations 1, and that is furnished according to the standards of care,1 provided in the 1[CEC PReP] CDC PrEP1 guidelines.
"HIV postexposure prophylaxis" means1[: tenofovir disoproxil fumarate (TDF) (300 mg) with emtricitabine (FTC) (200 mg), taken once daily, in combination with either raltegravir (400mg), taken twice daily, or dolutegravir (50mg), taken once daily; tenofovir disoproxil fumarate (TDF) (300 mg) with emtricitabine (FTC) (200 mg), taken once daily, in combination with darunavir (800mg) and ritonavir (100mg), taken once daily; or another] any1 drug or drug combination 1[determined by the State Board of Pharmacy to meet] authorized or approved by the United States Food and Drug Administration for the prevention of HIV that meets1 the 1[same]1 clinical 1[eligibility]1 recommendations 1, and that is furnished according to the standards of care,1 provided in the 1[CEC PRP] CDC PEP1 guidelines.
2. a. Notwithstanding any other provision of law to the contrary, a pharmacist may initiate and furnish HIV preexposure prophylaxis or HIV postexposure prophylaxis to a patient without an individual prescription pursuant to a standing order issued to the pharmacist by the Commissioner of Health or, if the commissioner is not a duly licensed physician, the Deputy Commissioner for Public Health Services. A standing order shall be issued to a pharmacist upon request, provided that the pharmacist satisfies the training requirements set forth in subsection b. of this section and certifies that the pharmacist will adhere to the requirements set forth in subsection c. of this section concerning the protocols for initiating and furnishing HIV preexposure prophylaxis and the requirements set forth in subsection d. of this section concerning the protocols for initiating and furnishing HIV postexposure prophylaxis to patients without an individual prescription. In no case shall a patient be authorized to waive the consultation required pursuant to subsection c. or subsection d. of this section.
b. A pharmacist shall not be authorized to furnish HIV preexposure prophylaxis or HIV postexposure prophylaxis to a patient without an individual prescription unless the pharmacist completes a training program, 1provided by the Department of Health or1 approved by the State Board of Pharmacy 1[in consultation with the Department of Health]1, concerning the use of HIV preexposure prophylaxis and HIV postexposure prophylaxis. At a minimum, the training program shall include information about financial assistance programs available to patients to assist with the costs of HIV preexposure prophylaxis and HIV postexposure prophylaxis.
c. A pharmacist shall furnish at least a 30-day supply, and up to a 1[60-day] 90-day1 supply, of HIV preexposure prophylaxis to a patient without an individual prescription if the following requirements are met:
(1) The patient is HIV-negative, as documented by a negative HIV test result obtained within the previous seven days from an HIV antigen/antibody test or antibody-only test or from a rapid, point-of-care fingerstick blood test approved by the federal Food and Drug Administration. If the patient does not provide evidence of a negative HIV test in accordance with this paragraph, the pharmacist shall 1administer an HIV test waived under the federal "Clinical Laboratory Improvement Amendments of 1988 (CLIA)," Pub. L. 100-578 (42 U.S.C. s.263a) or1 order an HIV test. If the test results are not ordered directly 1[to a] by the1 pharmacist, the pharmacist shall verify the test results to the pharmacist's satisfaction. If the patient tests positive for HIV infection, the pharmacist or person administering the test shall direct the patient to a primary care provider, provide the patient with information and resources concerning treatment providers and HIV treatment clinics in the region, and take all other actions required under State and federal law in response to a positive test for HIV;
(2) The patient does not report any signs or symptoms of acute HIV infection on a self-reported checklist of acute HIV infection signs and symptoms;
(3) The patient does not report taking any contraindicated medications, and the pharmacist reviews 1, to the extent possible,1 the patient's prescription monitoring information to confirm no contraindicated prescriptions have been issued or dispensed 1by the treating pharmacist or the pharmacy affiliated with the treating pharmacist to1 the patient in the past six months;
(4) The patient has not been furnished with HIV preexposure prophylaxis without an individual prescription within the past two years 1based on the information provided by the patient to the pharmacist or the information available in the patient's records1;
(5) The pharmacist provides counseling to the patient on the ongoing use of HIV preexposure prophylaxis, which may include education about side effects, safety during pregnancy and breastfeeding, adherence to recommended dosing, and the importance of timely testing and treatment, as applicable, for HIV, renal function, hepatitis B, hepatitis C, sexually transmitted diseases, and pregnancy for individuals of child-bearing capacity. The pharmacist shall notify the patient that the patient will not be eligible to continue receiving HIV preexposure prophylaxis unless the patient is seen by a primary care provider and issued a prescription for the HIV preexposure prophylaxis, and that the patient may be furnished with no more than a 1[60-day] 90-day1 supply of HIV preexposure prophylaxis by a pharmacist without an individual prescription within any given two year period;
(6) The pharmacist documents, to the extent possible, the services provided by the pharmacist in the patient's record in the record system maintained by the pharmacy, and includes the dispensation of the HIV preexposure prophylaxis in the prescription monitoring database established pursuant to P.L.2007, c.244 (C.45:1-45 et al.) with a note indicating the HIV preexposure prophylaxis was provided without an individual prescription pursuant to this section; and
(7) The pharmacist notifies the patient's primary care provider that the pharmacist furnished the patient with HIV preexposure prophylaxis pursuant to this section. If the patient does not have a primary care provider, or refuses to consent to the pharmacist providing notice to the primary care provider pursuant to this paragraph, the pharmacist shall provide the patient with a list of physicians and surgeons, clinics, or other health care service providers to contact regarding ongoing care for HIV preexposure prophylaxis. The Department of Health shall publish and maintain a current list of providers for pharmacists to use for the purposes of this paragraph, which list may be made available on the department's Internet website.
d. A pharmacist shall furnish a complete course of HIV postexposure prophylaxis to a patient without an individual prescription if the following requirements are met:
(1) The pharmacist confirms with the patient that the exposure to HIV occurred within the previous 72 hours and the patient otherwise meets the clinical criteria for HIV postexposure prophylaxis consistent with the 1standard of care outlined in the1 CDC PEP guidelines;
(2) The pharmacist provides HIV testing that is classified as waived under the federal "Clinical Laboratory Improvement Amendments of 1988," 42 U.S.C. s.263a, or determines the patient is willing to undergo HIV testing consistent with the CDC PEP guidelines;
(3) The pharmacist provides counseling to the patient on the use of HIV postexposure prophylaxis consistent with the 1standard of care outlined in the1 CDC PEP guidelines, which may include education about side effects, safety during pregnancy and breastfeeding, adherence to recommended dosing, and the importance of timely testing and treatment, as applicable, for HIV and sexually transmitted diseases. The pharmacist shall additionally inform the patient of the availability of HIV preexposure prophylaxis for persons who are at substantial risk of acquiring HIV; and
(4) The pharmacist notifies the patient's primary care provider that the pharmacist provided the patient with a complete course of HIV postexposure prophylaxis. If the patient does not have a primary care provider, or refuses to consent to the pharmacist providing notice to the primary care provider pursuant to this paragraph, the pharmacist shall provide the patient with a list of physicians and surgeons, clinics, or other health care service providers to contact regarding followup care for HIV postexposure prophylaxis 1[. The] or an Internet web link to this information that the1 Department of Health shall publish 1on the department's Internet website1 and maintain 1[a current list of providers]1 for pharmacists to use for the purposes of this paragraph1[, which list may be made available on the department's Internet website]1.
1e. A pharmacist ordering or providing HIV preexposure prophylaxis or HIV postexposure prophylaxis under this section shall be required to do so according to the same standards of care required under the CDC PEP guidelines or the CDC PrEP guidelines, as applicable, for a physician or other health care professional ordering or providing the identical service.
f. A licensed pharmacist who, in good faith, tests, furnishes or provides a patient care related to HIV preexposure prophylaxis and HIV postexposure prophylaxis pursuant to this section and based on information provided by said patient or the patient's legal representative shall not be subject to civil liability, criminal prosecution, disciplinary action, or other adverse action under any professional licensing statute for any injury or damages resulting from reliance on such information.1
3. a. (1) Except as provided in paragraph (2) of this subsection, no group or individual hospital service corporation contract providing hospital or medical expense benefits shall be 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, unless the contract provides benefits to any subscriber or other person covered thereunder for HIV preexposure prophylaxis and HIV postexposure prophylaxis furnished without an individual prescription pursuant to the requirements of section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill) without requiring prior authorization or step therapy.
(2) If the federal Food and Drug Administration has 1authorized or1 approved one or more therapeutic equivalents of a drug, device, or product for the prevention of HIV and AIDS, paragraph (1) of this subsection shall not be construed to require the contract to cover all therapeutically equivalent versions without prior authorization or step therapy, if at least one version is covered without prior authorization or step therapy.
b. 1Reimbursment issued under this section to a pharmacist shall be at a rate that is no less than the rate provided by the group or individual hospital service corporation contract to other non-physician practitioners if the reimbursement is for a service or procedure that meets the following criteria:
(1) the service or procedure is within the scope of practice of the treating pharmacist; and
(2) the service or procedure would otherwise be covered under the contract if provided by a healthcare provider, including a physician, advanced practice nurse, or physician assistant.
c. A contract offered by a group or individual hospital service corporation shall grant a licensed pharmacist receiving reimbursement under this section the same rights of participation, plan admission, and registration as may be granted by the contract to a healthcare provider, including a physician, advanced practice nurse, or physician assistant, who is reimbursed for an identical service.
d.1 A contract offered by a group or individual hospital service corporation shall not:
(1) prohibit, or permit a delegated pharmacy benefits manager to prohibit, a pharmacist from dispensing HIV preexposure prophylaxis or HIV postexposure prophylaxis; and
(2) be required to cover HIV preexposure prophylaxis that has been furnished by a pharmacist without an individual prescription pursuant to pursuant to section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill) in excess of a 1[60-day] 90-day1 supply for a single patient within a given two year period.
1[c.] e.1 Nothing in this section shall be construed to require a contract offered by a group or individual hospital service corporation to provide coverage for HIV preexposure prophylaxis or HIV postexposure prophylaxis furnished by a pharmacist at an out-of-network pharmacy, unless the contract has an out-of-network pharmacy benefit.
1[d.] f.1 The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium.
1[e.] g.1 As used in this section:
"HIV preexposure prophylaxis" means the same as that term is defined in section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"HIV postexposure prophylaxis" means the same as that term is defined in section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"Step therapy" means requiring that a lower-cost alternative to HIV preexposure prophylaxis or HIV postexposure prophylaxis be shown to have been ineffective as a condition of providing prescription benefits coverage for the prophylaxis.
4. a. (1) Except as provided in paragraph (2) of this subsection, no group or individual medical service corporation contract providing hospital or medical expense benefits shall be 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, unless the contract provides benefits to any subscriber or other person covered thereunder for HIV preexposure prophylaxis and HIV postexposure prophylaxis furnished without an individual prescription pursuant to the requirements of section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill) without requiring prior authorization or step therapy.
(2) If the federal Food and Drug Administration has 1authorized or1 approved one or more therapeutic equivalents of a drug, device, or product for the prevention of HIV and AIDS, paragraph (1) of this subsection shall not be construed to require the contract to cover all therapeutically equivalent versions without prior authorization or step therapy, if at least one version is covered without prior authorization or step therapy.
b. 1Reimbursment issued under this section to a pharmacist shall be at a rate that is no less than the rate provided by the group or individual medical service corporation contract to other non-physician practitioners if the reimbursement is for a service or procedure that meets the following criteria:
(1) the service or procedure is within the scope of practice of the treating pharmacist; and
(2) the service or procedure would otherwise be covered under the contract if provided by a healthcare provider, including a physician, advanced practice nurse, or physician assistant.
c. A contract offered by a group or individual medical service corporation shall grant a licensed pharmacist receiving reimbursement under this section the same rights of participation, plan admission, and registration as may be granted by the contract to a healthcare provider, including a physician, advanced practice nurse, or physician assistant, who is reimbursed for an identical service.
d.1 A contract offered by a group or individual medical service corporation shall not:
(1) prohibit, or permit a delegated pharmacy benefits manager to prohibit, a pharmacist from dispensing HIV preexposure prophylaxis or HIV postexposure prophylaxis; and
(2) be required to cover HIV preexposure prophylaxis that has been furnished by a pharmacist without an individual prescription pursuant to pursuant to section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill) in excess of a 1[60-day] 90-day1 supply for a single patient within a given two year period.
1[c.] e.1 Nothing in this section shall be construed to require a contract offered by a group or individual medical service corporation to provide coverage for HIV preexposure prophylaxis or HIV postexposure prophylaxis furnished by a pharmacist at an out-of-network pharmacy, unless the contract has an out-of-network pharmacy benefit.
1[d.] f.1 The provisions of this section shall apply to all contracts in which the group or individual medical service corporation has reserved the right to change the premium.
1[e.] g.1 As used in this section:
"HIV preexposure prophylaxis" means the same as that term is defined in section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"HIV postexposure prophylaxis" means the same as that term is defined in section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"Step therapy" means requiring that a lower-cost alternative to HIV preexposure prophylaxis or HIV postexposure prophylaxis be shown to have been ineffective as a condition of providing prescription benefits coverage for the prophylaxis.
5. a. (1) Except as provided in paragraph (2) of this subsection, no group or individual health service corporation contract providing hospital or medical expense benefits shall be 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, unless the contract provides benefits to any subscriber or other person covered thereunder for HIV preexposure prophylaxis and HIV postexposure prophylaxis furnished without an individual prescription pursuant to the requirements of section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill) without requiring prior authorization or step therapy.
(2) If the federal Food and Drug Administration has1authorized or1 approved one or more therapeutic equivalents of a drug, device, or product for the prevention of HIV and AIDS, paragraph (1) of this subsection shall not be construed to require the contract to cover all therapeutically equivalent versions without prior authorization or step therapy, if at least one version is covered without prior authorization or step therapy.
b. 1Reimbursment issued under this section to a pharmacist shall be at a rate that is no less than the rate provided by the group or individual health service corporation contract to other non-physician practitioners if the reimbursement is for a service or procedure that meets the following criteria:
(1) the service or procedure is within the scope of practice of the treating pharmacist; and
(2) the service or procedure would otherwise be covered under the contract if provided by a healthcare provider, including a physician, advanced practice nurse, or physician assistant.
c. A contract offered by a group or individual health service corporation shall grant a licensed pharmacist receiving reimbursement under this section the same rights of participation, plan admission, and registration as may be granted by the contract to a healthcare provider, including a physician, advanced practice nurse, or physician assistant, who is reimbursed for an identical service.
d.1 A contract offered by a group or individual health service corporation shall not:
(1) prohibit, or permit a delegated pharmacy benefits manager to prohibit, a pharmacist from dispensing HIV preexposure prophylaxis or HIV postexposure prophylaxis; and
(2) be required to cover HIV preexposure prophylaxis that has been furnished by a pharmacist without an individual prescription pursuant to pursuant to section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill) in excess of a 1[60-day] 90-day1 supply for a single patient within a given two year period.
1[c.] e.1 Nothing in this section shall be construed to require a contract offered by a health service corporation to provide coverage for HIV preexposure prophylaxis or HIV postexposure prophylaxis furnished by a pharmacist at an out-of-network pharmacy, unless the contract has an out-of-network pharmacy benefit.
1[d.] f.1 The provisions of this section shall apply to all contracts in which the health service corporation has reserved the right to change the premium.
1[e.] g.1 As used in this section:
"HIV preexposure prophylaxis" means the same as that term is defined in section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"HIV postexposure prophylaxis" means the same as that term is defined in section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"Step therapy" means requiring that a lower-cost alternative to HIV preexposure prophylaxis or HIV postexposure prophylaxis be shown to have been ineffective as a condition of providing prescription benefits coverage for the prophylaxis.
6. a. (1) Except as provided in paragraph (2) of this subsection, no individual health insurance policy providing hospital or medical expense benefits shall be 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, unless the policy provides benefits to any named insured or other person covered thereunder for HIV preexposure prophylaxis and HIV postexposure prophylaxis furnished without an individual prescription pursuant to the requirements of section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill) without requiring prior authorization or step therapy.
(2) If the federal Food and Drug Administration has1authorized or1 approved one or more therapeutic equivalents of a drug, device, or product for the prevention of HIV and AIDS, paragraph (1) of this subsection shall not be construed to require the policy to cover all therapeutically equivalent versions without prior authorization or step therapy, if at least one version is covered without prior authorization or step therapy.
b. 1Reimbursment issued under this section to a pharmacist shall be at a rate that is no less than the rate provided by the individual health insurance policy to other non-physician practitioners if the reimbursement is for a service or procedure that meets the following criteria:
(1) the service or procedure is within the scope of practice of the treating pharmacist; and
(2) the service or procedure would otherwise be covered under the policy if provided by a healthcare provider, including a physician, advanced practice nurse, or physician assistant.
c. An individual health insurance policy shall grant a licensed pharmacist receiving reimbursement under this section the same rights of participation, plan admission, and registration as may be granted by the policy to a healthcare provider, including a physician, advanced practice nurse, or physician assistant, who is reimbursed for an identical service.
d.1 An individual health insurance policy shall not:
(1) prohibit, or permit a delegated pharmacy benefits manager to prohibit, a pharmacist from dispensing HIV preexposure prophylaxis or HIV postexposure prophylaxis; and
(2) be required to cover HIV preexposure prophylaxis that has been furnished by a pharmacist without an individual prescription pursuant to pursuant to section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill) in excess of a 1[60-day] 90-day1 supply for a single patient within a given two year period.
1[c.] e.1 Nothing in this section shall be construed to require an individual health insurance policy to provide coverage for HIV preexposure prophylaxis or HIV postexposure prophylaxis furnished by a pharmacist at an out-of-network pharmacy, unless the contract has an out-of-network pharmacy benefit.
1[d.] f.1 The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.
1[e.] g.1 As used in this section:
"HIV preexposure prophylaxis" means the same as that term is defined in section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"HIV postexposure prophylaxis" means the same as that term is defined in section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"Step therapy" means requiring that a lower-cost alternative to HIV preexposure prophylaxis or HIV postexposure prophylaxis be shown to have been ineffective as a condition of providing prescription benefits coverage for the prophylaxis.
7. a. (1) Except as provided in paragraph (2) of this subsection, no group health insurance policy providing hospital or medical expense benefits shall be 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, unless the policy provides benefits to any named insured or other person covered thereunder for HIV preexposure prophylaxis and HIV postexposure prophylaxis furnished without an individual prescription pursuant to the requirements of section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill) without requiring prior authorization or step therapy.
(2) If the federal Food and Drug Administration has 1authorized or1 approved one or more therapeutic equivalents of a drug, device, or product for the prevention of HIV and AIDS, paragraph (1) of this subsection shall not be construed to require the policy to cover all therapeutically equivalent versions without prior authorization or step therapy, if at least one version is covered without prior authorization or step therapy.
b. 1Reimbursment issued under this section to a pharmacist shall be at a rate that is no less than the rate provided by the group health insurance policy to other non-physician practitioners if the reimbursement is for a service or procedure that meets the following criteria:
(1) the service or procedure is within the scope of practice of the treating pharmacist; and
(2) the service or procedure would otherwise be covered under the policy if provided by a healthcare provider, including a physician, advanced practice nurse, or physician assistant.
c. A group health insurance policy shall grant a licensed pharmacist receiving reimbursement under this section the same rights of participation, plan admission, and registration as may be granted by the policy to a healthcare provider, including a physician, advanced practice nurse, or physician assistant, who is reimbursed for an identical service.
d.1 A group health insurance policy shall not:
(1) prohibit, or permit a delegated pharmacy benefits manager to prohibit, a pharmacist from dispensing HIV preexposure prophylaxis or HIV postexposure prophylaxis; and
(2) be required to cover HIV preexposure prophylaxis that has been furnished by a pharmacist without an individual prescription pursuant to pursuant to section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill) in excess of a 1[60-day] 90-day1 supply for a single patient within a given two year period.
1[c.] e.1 Nothing in this section shall be construed to require a group health insurance policy to provide coverage for HIV preexposure prophylaxis or HIV postexposure prophylaxis furnished by a pharmacist at an out-of-network pharmacy, unless the contract has an out-of-network pharmacy benefit.
1[d.] f.1 The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.
1[e.] g.1 As used in this section:
"HIV preexposure prophylaxis" means the same as that term is defined in section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"HIV postexposure prophylaxis" means the same as that term is defined in section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"Step therapy" means requiring that a lower-cost alternative to HIV preexposure prophylaxis or HIV postexposure prophylaxis be shown to have been ineffective as a condition of providing prescription benefits.
8. a. (1) Except as provided in paragraph (2) of this subsection, every individual health benefits plan that is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.) or approved for issuance or renewal in this State, on or after the effective date of this act, shall provide benefits to any person covered thereunder for expenses incurred for HIV preexposure prophylaxis and HIV postexposure prophylaxis furnished without an individual prescription pursuant to the requirements of section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill) without requiring prior authorization or step therapy.
(2) If the federal Food and Drug Administration has 1authorized or1 approved one or more therapeutic equivalents of a drug, device, or product for the prevention of HIV and AIDS, paragraph (1) of this subsection shall not be construed to require the plan to cover all therapeutically equivalent versions without prior authorization or step therapy, if at least one version is covered without prior authorization or step therapy.
b. 1Reimbursment issued under this section to a pharmacist shall be at a rate that is no less than the rate provided by the individual health benefits plan to other non-physician practitioners if the reimbursement is for a service or procedure that meets the following criteria:
(1) the service or procedure is within the scope of practice of the treating pharmacist; and
(2) the service or procedure would otherwise be covered under the plan if provided by a healthcare provider, including a physician, advanced practice nurse, or physician assistant.
c. An individual health benefits plan shall grant a licensed pharmacist receiving reimbursement under this section the same rights of participation, plan admission, and registration as may be granted by the plan to a healthcare provider, including a physician, advanced practice nurse, or physician assistant, who is reimbursed for an identical service.
d.1 An individual health benefits plan shall not:
(1) prohibit, or permit a delegated pharmacy benefits manager to prohibit, a pharmacist from dispensing HIV preexposure prophylaxis or HIV postexposure prophylaxis; and
(2) be required to cover HIV preexposure prophylaxis that has been furnished by a pharmacist without an individual prescription pursuant to pursuant to section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill) in excess of a 1[60-day] 90-day1 supply for a single patient within a given two year period.
1[c.] e.1 Nothing in this section shall be construed to require an individual health benefit plan to provide coverage for HIV preexposure prophylaxis or HIV postexposure prophylaxis furnished by a pharmacist at an out-of-network pharmacy, unless the contract has an out-of-network pharmacy benefit.
1[d.] f.1 The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.
1[e.] g.1 As used in this section:
"HIV preexposure prophylaxis" means the same as that term is defined in section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"HIV postexposure prophylaxis" means the same as that term is defined in section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"Step therapy" means requiring that a lower-cost alternative to HIV preexposure prophylaxis or HIV postexposure prophylaxis be shown to have been ineffective as a condition of providing prescription benefits.
9. a. (1) Except as provided in paragraph (2) of this subsection, every small employer health benefits plan that is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) or approved for issuance or renewal in this State, on or after the effective date of this act, shall provide benefits to any person covered thereunder for HIV preexposure prophylaxis and HIV postexposure prophylaxis furnished without an individual prescription pursuant to the requirements of section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill) without requiring prior authorization or step therapy.
(2) If the federal Food and Drug Administration has 1authorized or1 approved one or more therapeutic equivalents of a drug, device, or product for the prevention of HIV and AIDS, paragraph (1) of this subsection shall not be construed to require the plan to cover all therapeutically equivalent versions without prior authorization or step therapy, if at least one version is covered without prior authorization or step therapy.
b. 1Reimbursment issued under this section to a pharmacist shall be at a rate that is no less than the rate provided by the small employer health benefits plan to other non-physician practitioners if the reimbursement is for a service or procedure that meets the following criteria:
(1) the service or procedure is within the scope of practice of the treating pharmacist; and
(2) the service or procedure would otherwise be covered under the plan if provided by a healthcare provider, including a physician, advanced practice nurse, or physician assistant.
c. A small employer health benefits plan shall grant a licensed pharmacist receiving reimbursement under this section the same rights of participation, plan admission, and registration as may be granted by the plan to a healthcare provider, including a physician, advanced practice nurse, or physician assistant, who is reimbursed for an identical service.
d.1 A small employer health benefits plan shall not:
(1) prohibit, or permit a delegated pharmacy benefits manager to prohibit, a pharmacist from dispensing HIV preexposure prophylaxis or HIV postexposure prophylaxis; and
(2) be required to cover HIV preexposure prophylaxis that has been furnished by a pharmacist without an individual prescription pursuant to pursuant to section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill) in excess of a 1[60-day] 90-day1 supply for a single patient within a given two year period.
1[c.] e.1 Nothing in this section shall be construed to require a small employer health benefit plan to provide coverage for HIV preexposure prophylaxis or HIV postexposure prophylaxis furnished by a pharmacist at an out-of-network pharmacy, unless the contract has an out-of-network pharmacy benefit.
1[d.] f.1 The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.
1[e.] g.1 As used in this section:
"HIV preexposure prophylaxis" means the same as that term is defined in section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"HIV postexposure prophylaxis" means the same as that term is defined in section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"Step therapy" means requiring that a lower-cost alternative to HIV preexposure prophylaxis or HIV postexposure prophylaxis be shown to have been ineffective as a condition of providing prescription benefits.
10. a. (1) Except as provided in paragraph (2) of this subsection, notwithstanding any provision of law to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of this act unless the health maintenance organization provides health care services to any enrollee for expenses incurred for HIV preexposure prophylaxis and HIV postexposure prophylaxis furnished without an individual prescription pursuant to the requirements of section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill) without requiring prior authorization or step therapy.
(2) If the federal Food and Drug Administration has 1authorized or1 approved one or more therapeutic equivalents of a drug, device, or product for the prevention of HIV and AIDS, paragraph (1) of this subsection shall not be construed to require the plan to cover all therapeutically equivalent versions without prior authorization or step therapy, if at least one version is covered without prior authorization or step therapy.
b. 1Reimbursment issued under this section to a pharmacist shall be at a rate that is no less than the rate provided by the health maintenance organization to other non-physician practitioners if the reimbursement is for a service or procedure that meets the following criteria:
(1) the service or procedure is within the scope of practice of the treating pharmacist; and
(2) the service or procedure would otherwise be covered by the health maintenance organization if provided by a healthcare provider, including a physician, advanced practice nurse, or physician assistant.
c. A health maintenance organization shall grant a licensed pharmacist receiving reimbursement under this section the same rights of participation, plan admission, and registration as may be granted by the health maintenance organization to a healthcare provider, including a physician, advanced practice nurse, or physician assistant, who is reimbursed for an identical service.
d.1 A health maintenance organization shall not:
(1) prohibit, or permit a delegated pharmacy benefits manager to prohibit, a pharmacist from dispensing HIV preexposure prophylaxis or HIV postexposure prophylaxis; and
(2) be required to cover HIV preexposure prophylaxis that has been furnished by a pharmacist without an individual prescription pursuant to pursuant to section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill) in excess of a 1[60-day] 90-day1 supply for a single patient within a given two year period.
1[c.] e.1 Nothing in this section shall be construed to require a health maintenance organization to provide coverage for HIV preexposure prophylaxis or HIV postexposure prophylaxis furnished by a pharmacist at an out-of-network pharmacy, unless the contract has an out-of-network pharmacy benefit.
1[d.] f.1 The benefits shall be provided to the same extent as for any other medical condition under the contract.
1[e.] g.1 As used in this section:
"HIV preexposure prophylaxis" means the same as that term is defined in section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"HIV postexposure prophylaxis" means the same as that term is defined in section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"Step therapy" means requiring that a lower-cost alternative to HIV preexposure prophylaxis or HIV postexposure prophylaxis be shown to have been ineffective as a condition of providing prescription benefits.
11. a. (1) Notwithstanding any State law or regulation to the contrary, and except as provided in paragraph (2) of this subsection, the Department of Human Services shall ensure that the provision of benefits for HIV preexposure prophylaxis and HIV postexposure prophylaxis furnished without an individual prescription pursuant to the requirements of section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill) to eligible persons under the Medicaid program, established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), shall be provided without the imposition of any prior authorization or step therapy requirements.
(2) If the federal Food and Drug Administration has 1authorized or1 approved one or more therapeutic equivalents of a drug, device, or product for the prevention of HIV and AIDS, paragraph (1) of this subsection shall not be construed to require the department to ensure coverage of all therapeutically equivalent versions without prior authorization or step therapy, if at least one version is covered without prior authorization or step therapy.
b. 1Reimbursment issued under this section to a pharmacist shall be at a rate that is no less than the rate provided by the Department of Human Services to other non-physician practitioners if the reimbursement is for a service or procedure that meets the following criteria:
(1) the service or procedure is within the scope of practice of the treating pharmacist; and
(2) the service or procedure would otherwise be covered by the department if provided by a healthcare provider, including a physician, advanced practice nurse, or physician assistant.
c. The Department of Human Services shall grant a licensed pharmacist receiving reimbursement under this section the same rights of participation, plan admission, and registration as may be granted by the department to a healthcare provider, including a physician, advanced practice nurse, or physician assistant, who is reimbursed for an identical service.
d.1 As used in this section:
"HIV preexposure prophylaxis" means the same as that term is defined in section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"HIV postexposure prophylaxis" means the same as that term is defined in section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"Step therapy" means requiring that a lower-cost alternative to HIV preexposure prophylaxis or HIV postexposure prophylaxis be shown to have been ineffective as a condition of providing prescription benefits coverage for the prophylaxis.
12. a. (1) Except as provided in paragraph (2) of this subsection, the State Health Benefits Commission shall provide benefits to each person covered under the State Health Benefits Program for expenses incurred for HIV preexposure prophylaxis and HIV postexposure prophylaxis furnished without an individual prescription pursuant to the requirements of section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill) without requiring prior authorization or step therapy.
(2) If the federal Food and Drug Administration has 1authorized or1 approved one or more therapeutic equivalents of a drug, device, or product for the prevention of HIV and AIDS, paragraph (1) of this subsection shall not be construed to require the contract to cover all therapeutically equivalent versions without prior authorization or step therapy, if at least one version is covered without prior authorization or step therapy.
b. The State Health Benefits Commission shall not:
(1) prohibit, or permit a delegated pharmacy benefits manager to prohibit, a pharmacist from dispensing HIV preexposure prophylaxis or HIV postexposure prophylaxis; and
(2) be required to cover HIV preexposure prophylaxis that has been furnished by a pharmacist without an individual prescription pursuant to pursuant to section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill) in excess of a 1[60-day] 90-day1 supply for a single patient within a given two year period.
c. Nothing in this section shall be construed to require the State Health Benefits Commission to provide coverage for HIV preexposure prophylaxis or HIV postexposure prophylaxis furnished by a pharmacist at an out-of-network pharmacy, unless the contract has an out-of-network pharmacy benefit.
d. The benefits shall be provided to the same extent as for any other medical condition under the contract.
e. As used in this section:
"HIV preexposure prophylaxis" means the same as that term is defined in section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"HIV postexposure prophylaxis" means the same as that term is defined in section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"Step therapy" means requiring that a lower-cost alternative to HIV preexposure prophylaxis or HIV postexposure prophylaxis be shown to have been ineffective as a condition of providing prescription benefits.
13. The Commissioner of Human Services shall apply for such State plan amendments or waivers as may be necessary to implement the provisions of section 11 of this act and to secure federal financial participation for State Medicaid expenditures under the federal Medicaid program.
14. a. Within 90 days after the date of enactment of this act, and notwithstanding the provisions of the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to the contrary, the State Board of Pharmacy, in consultation with the Department of Health, immediately upon filing proper notice with the Office of Administrative Law, shall adopt rules and regulations as may be necessary to implement the provisions of this act.
b. The rules and
regulations adopted pursuant to subsection a. of this section shall be in
effect for a period not to exceed one year from the date of filing. These
rules and regulations shall thereafter be adopted, amended, or readopted by the
board, in consultation with the Department of Health, in accordance with the
requirements of the "Administrative Procedure Act," P.L.1968, c.410
(C.52:14B-1 et seq.).
15. This act shall take effect immediately.
