2017 New Jersey Revised Statutes
Section 17B:26-2.1i - Requirements for individual health insurer providing benefits for pharmacy services.

17B:26-2.1i Requirements for individual health insurer providing benefits for pharmacy services.

4. a. Notwithstanding any other provision of law to the contrary, no individual health insurance policy which provides benefits for pharmacy services, prescription drugs, or for participation in a prescription drug plan, shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State on or after the effective date of this act, unless the policy:

(1) Permits the insured, at the time of issuance, amendment or renewal, to select benefit coverage allowing the insured to choose a pharmacy or pharmacist for the provision of prescription drugs or pharmacy services, provided that any pharmacist or pharmacy selected by the insured is registered pursuant to R.S.45:14-1 et seq.;

(2) Provides that no pharmacy or pharmacist shall be denied the right to participate as a preferred provider or as a contracting provider, under the same terms and conditions currently applicable to all other preferred or contracting providers, if the policy provides for coverage by contracted or preferred providers for pharmaceutical services, provided the pharmacy or pharmacist is registered pursuant to R.S.45:14-1 et seq., and accepts the terms and conditions of the policy;

(3) Provides that no copayment, fee, or other condition shall be imposed upon an insured selecting a participating or contracting pharmacist or pharmacy that is not also equally imposed upon all insureds selecting a participating or contracting pharmacist or pharmacy;

(4) (a) Provides that no insured shall be required to obtain pharmacy services and prescription drugs from a mail service pharmacy;

(b) Provides for no differential in any copayment applicable to any prescription drug of the same strength, quantity and days' supply, whether obtained from a mail service pharmacy or a non-mail service pharmacy, provided that the non-mail service pharmacy agrees to the same terms, conditions, price and services applicable to the mail service pharmacy; and

(c) Provides that the limit on days' supply is the same whether the prescription drug is obtained from a mail service pharmacy or a non-mail service pharmacy, and that the limit shall not be less than 90 days;

(5) Sets forth the auditing procedures to be used by the insurer and includes a provision that any audit shall take place at a time mutually agreeable to the pharmacy or pharmacist and the auditor. No audit by an insurer shall include a review of any document relating to any person or prescription plan other than those reimbursable by the insurer;

(6) Provides that the insurer, or any agent or intermediary thereof, including a third party administrator, shall not restrict or prohibit, directly or indirectly, a pharmacy from charging the insured for services rendered by the pharmacy that are in addition to charges for the drug, for dispensing the drug or for prescription counseling. Services rendered by the pharmacy for which additional charges are imposed shall be subject to the approval of the Board of Pharmacy. A pharmacy shall disclose to the purchaser the charges for the additional services and the purchaser's out-of-pocket cost for those services prior to dispensing the drug. A pharmacy shall not impose any additional charges for patient counseling or for other services required by the Board of Pharmacy or State or federal law;

(7) The provisions of P.L.1999, c.395 shall apply to all policies delivered. issued or renewed on or after the effective date of P.L.1999, c.395.

b. Nothing in this section shall be construed to operate to add any benefit, to increase the scope of any benefit, or to increase any benefit level under any policy.

c. This section shall apply to all individual health insurance policies in which the insurer has reserved the right to change the premium.

L.1993,c.378,s.4; amended 1999, c.395, s.4.

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