New Jersey Revised Statutes § 17:48e-35.7 - Requirements For Health Service Corporation Providing Benefits For Pharmacy Services.

17:48E-35.7 Requirements for health service corporation providing benefits for pharmacy services.

3. a. Notwithstanding any other provisions of law to the contrary, no group or individual health service corporation contract 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 contract:

(1)Permits the subscriber, at the time of issuance, amendment or renewal, to select benefit coverage allowing the subscriber to choose a pharmacy or pharmacist for the provision of prescription drugs or pharmacy services, provided that any pharmacist or pharmacy selected by the subscriber 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 contract 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 contract;

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

(4) (a) Provides that no subscriber 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 health service corporation 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 a health service corporation shall include a review of any document relating to any person or prescription plan other than those reimbursable by the health service corporation;

(6)Provides that the health service corporation, or any agent or intermediary thereof, including a third party administrator, shall not restrict or prohibit, directly or indirectly, a pharmacy from charging the subscriber 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 contracts 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 contract.

c.This section shall apply to all health service corporation contracts in which the health service corporation has reserved the right to change the subscriber charge.

L.1993,c.378,s.3; amended 1999, c.395, s.3.

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Last modified: October 11, 2016