N.J.S.A. 17B:27F-6.1 — Requirements for pharmacy benefits managers.

17B:27F-6.1 Requirements for pharmacy benefits managers. 4. a. The annual limitation on cost-sharing amounts provided for in section 1302 of the Patient Protection and Affordable Care Act, Pub.L.111-148 (42 U.S.C. s.18022) shall apply to all health care services covered under any health benefits plan offered or issued by a carrier in this State, including a health benefits plan administered by a pharmacy benefits manager. Nothing in this subsection shall be construed to limit or supersede the authority of the Department of Banking and Insurance to impose additional cost-sharing limits consistent with State law and regulations, including minimum standards established pursuant to N.J.A.C.11:22-5.1 et seq. b. When calculating a covered person�s contribution to any applicable cost-sharing amount requirement, a pharmacy benefits manager shall give credit for the amount, or any portion thereof, of any cost-sharing amount paid by the covered person or on behalf of the covered person by another party. If a health benefits plan qualifies as a high-deductible health plan for which medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), this subsection shall apply to a high-deductible health plan with respect to the deductible after the covered person has satisfied the minimum deductible required under section 223, except for with respect to items or services that are preventive care pursuant to section 223(c)(2)(C) of the federal Internal Revenue Code (26 U.S.C. s.223), in which case the requirements of this subsection shall apply regardless of whether the minimum deductible under section 223 has been satisfied. c. A pharmacy benefits manager shall not directly or indirectly set, alter, implement, or condition the terms of health benefits plan coverage, including the benefit design, based in part or entirely on information about the availability or amount of financial or product assistance available for a prescription drug. d. By March 31 of each year, each pharmacy benefits manager authorized to conduct business in the State shall certify to the Commissioner of Banking and Insurance, in a form and manner as determined by the commissioner, that it has fully and completely complied with the requirements of this section throughout the prior calendar year. The certification shall be signed by the chief executive officer, chief financial officer, or designee, of the pharmacy benefits manager. e. The Commissioner of Banking and Insurance, pursuant to the �Administrative Procedure Act,� P.L.1968, c.410 (C.52:14B-1 et seq.), shall adopt rules and regulations to effectuate the purposes of this section. f. As used in this section: �Cost-sharing amount� means any copayment, coinsurance, deductible, or other similar charges required of a covered person for a health care service covered by a health benefits plan, including a prescription drug benefits plan, and paid by or on behalf of the covered person. �Health benefits plan� means a benefits plan which pays hospital or medical expense benefits for covered services, or prescription drug benefits for covered services, and is delivered or issued for delivery in this State by or through a carrier or any other sponsor. For the purposes of P.L.2015, c.179 (C.17B:27F-1 et seq.), �health benefits plan� shall not include the following plans, policies or contracts: accident only; credit disability; long-term care; Medicare supplement coverage; TRICARE supplement coverage; coverage for Medicare services pursuant to a contract with the United States government; the State Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.); coverage arising out of a worker's compensation or similar law; the State Health Benefits Program; the School Employees' Health Benefits Program; or a self-insured health benefits plan governed by the provisions of the federal �Employee Retirement Income Security Act of 1974,� 29 U.S.C. s.1001 et seq.; coverage under a policy of private passenger automobile insurance issued pursuant to P.L.1972, c.70 (C.39:6A-1 et seq.); or hospital confinement indemnity coverage. �Health care service� means an item or service furnished to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury, or disability. �Pharmacy benefits manager� means a corporation, business, or other entity, or unit within a corporation, business, or other entity, that, pursuant to a contract or under an employment relationship with a carrier, health benefits plan, self-insurance plan, or other third-party payer, either directly or through an intermediary, provides one or more pharmacy benefits management services on behalf of a carrier, health benefits plan, self-insurance plan, and or other third-party payer, and any agent, contractor, intermediary, affiliate, subsidiary, or related entity of a person who facilitates, provides, directs, or oversees the provision of the pharmacy benefits management services. �Pharmacy benefits management services� means: negotiating the price of prescription drugs, including negotiating and contracting for direct or indirect rebates, discounts, or other price concessions; managing the aspects of a prescription drug benefit, including, but not limited to, the processing and payment of claims for prescription drugs; arranging alternative access to or funding for prescription drugs; the performance of drug utilization review; the processing of drug prior authorization requests; the adjudication of appeals or grievances related to the prescription drug benefit; contracting with network pharmacies; controlling the cost of covered prescription drugs; managing or providing data relating to the prescription drug benefit; or the provision of services related thereto; performance of any administrative; managerial; clinical; pricing; financial; reimbursement; data administration or reporting; or billing service; and other services as the Commissioner of Banking and Insurance may deem necessary. L.2025, c.199, s.4.

This is the verbatim text of N.J.S.A. 17B:27F-6.1, retrieved from the New Jersey Legislature's public statute corpus. Statutes are amended periodically — for the most current version, check the external source link above. Kyzer is not a law firm and this page is not legal advice.