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17B:27-46.1g. .Group health insurance policy, benefits for "off-label" drugs required
6. a. Except as otherwise provided in P.L.1992, c.162 (C.17B:27A-17 et seq.), no group health insurance policy which provides benefits for expenses incurred in prescribing drugs approved by the federal Food and Drug Administration 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 provides benefits to any policyholder or other person covered thereunder for expenses incurred in prescribing a drug for a treatment for which it has not been approved by the Food and Drug Administration if the drug is recognized as being medically appropriate for the specific treatment for which the drug has been prescribed in one of the following established reference compendia:
(1) the American Medical Association Drug Evaluations;
(2) the American Hospital Formulary Service Drug Information;
(3) the United States Pharmacopoeia Drug Information;
or, it is recommended by a clinical study or review article in a major-peer reviewed professional journal.
b. Notwithstanding the provisions of this section, coverage shall not be required for any experimental or investigational drug or any drug which the Food and Drug Administration has determined to be contraindicated for the specific treatment for which the drug has been prescribed. The benefits provided pursuant to this section shall be provided to the same extent as other benefits under the policy for drugs prescribed for treatments approved by the Food and Drug Administration.
c. This section shall apply to all group health insurance policies in which the insurer has reserved the right to change the premium.
d. Any coverage of a drug required by this section shall also include medically necessary services associated with the administration of the drug.
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Last modified: February 14, 2012