N.J.S.A. 52:14-17.29z — SHBC to provide coverage for donated human breast milk.

52:14-17.29z SHBC to provide coverage for donated human breast milk. 9. a. The State Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits shall provide coverage for expenses incurred in the provision of pasteurized donated human breast milk, which may include human milk fortifiers if indicated by the prescribing licensed medical practitioner, provided that: (1) the covered person is an infant under the age of six months; (2) the milk is obtained from a human milk bank that meets quality guidelines established by the Department of Health ; and (3) a licensed medical practitioner has issued an order for an infant who is medically or physically unable to receive maternal breast milk or participate in breast feeding or whose mother is medically or physically unable to produce maternal breast milk in sufficient quantities or participate in breast feeding despite optimal lactation support; or (4) a licensed medical practitioner has issued an order for an infant who meets any of the following conditions: (a) a body weight below healthy levels determined by the licensed medical practitioner; (b) a congenital or acquired condition that places the infant at a high risk for development of necrotizing enterocolitis; or (c) a congenital or acquired condition that may benefit from the use of donor breast milk as determined by the Department of Health. b. Nothing in this section shall preclude the carrier from performing utilization review, including periodic review of the medical necessity of a particular service. c. The benefits shall be provided to the same extent as for any other prescribed items under the contract. d. If there is no supply of human breast milk that meets the requirements of paragraph (2) of subsection a. of this section, the carrier shall not be required to provide coverage of expenses pursuant to this section. L.2017, c.309, s.9. 52:14-17.29aa SHBC not to provide coverage for certain early elective deliveries. 4. a. Notwithstanding any other law or regulation to the contrary, the State Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital and medical expense benefits shall not provide coverage for a non-medically indicated early elective delivery performed at a hospital on a pregnant woman earlier than the 39th week of gestation. b. As used in this section, "non-medically indicated early elective delivery" means the artificial start of the birth process through medical interventions or other methods, also known as labor induction, or the surgical delivery of a baby via a cesarean section for purposes or reasons that are not fully consistent with established standards of clinical care as provided by the American College of Obstetricians and Gynecologists. L.2019, c.87, s.4. 52:14-17.29bb State Health Benefits Commission to provide coverage for standard fertility preservation services. 6. a. The State Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits shall provide coverage for standard fertility preservation services when a medically necessary treatment may directly or indirectly cause iatrogenic infertility. For the purposes of this section: "Iatrogenic infertility" means an impairment of fertility caused by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes. "May directly or indirectly cause" means a medical treatment with a likely side effect of iatrogenic infertility as established by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or as defined by the New Jersey Department of Health. "Standard fertility preservation services" means procedures consistent with established medical practices and professional guidelines published by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or as defined by the New Jersey Department of Health. "Standard fertility preservation services" shall not include the storage of sperm or oocytes. The benefits shall be provided to the same extent as for any other medical condition under the contract. The same copayments, deductibles, and benefit limits shall apply to the provision of standard fertility preservation services pursuant to this section as those applied to other medical or surgical benefits under the contract. b. The State Health Benefits Commission shall not purchase a contract that determines the provision of standard fertility preservation services based on a covered person's expected length of life, present or predicted disability, degree of medical dependency, perceived quality of life, or other health conditions, or based on personal characteristics, including age, sex, sexual orientation, marital status, or gender identity. L.2019, c.306, s.6. 52:14-17.29cc SHBC to provide coverage for breastfeeding support. 9. a. The State Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits shall provide coverage for comprehensive lactation support, counseling, and consultation, and the costs for renting or purchasing breastfeeding equipment, in conjunction with each birth, for the duration of breastfeeding for contract enrollees, with no cost-sharing. b. Coverage of breastfeeding equipment shall include: (1) Purchase of a single-user breast pump, subject to the following conditions: (a) A contract shall cover the purchase of a double electric breast pump. If an enrollee requests a manual pump in lieu of the double electric breast pump, the contract shall cover the purchase of a manual pump. (b) A double electric breast pump provided pursuant to this paragraph shall be of sufficient power and durability to establish and maintain milk supply for the duration of breastfeeding. (c) A contract shall not require documentation of medical necessity, prior authorization, or a prescription for a breast pump provided pursuant to this paragraph. (d) Coverage shall be available at any time during pregnancy and the postpartum period, and shall continue for the duration of breastfeeding as defined by the contract enrollee. (e) Coverage for breast pumps shall include repair or replacement if necessary. (2) Rental or purchase of a multi-user breast pump, on the recommendation of a licensed health care provider, subject to the following conditions: (a) When recommended by a licensed health care provider, a contract shall provide coverage for a multi-user breast pump. (b) A contract may provide for a determination as to whether a rental or purchase is covered. (c) Coverage for a multi-user breast pump shall be covered without regard to coverage or acquisition of a single-user breast pump. (d) A contract may provide for requirement of a letter of medical necessity from a lactation consultant or other health care provider for coverage of a multi-user pump. The letter shall not interfere with the timely acquisition of a multi-user pump. (3) Coverage of breastfeeding equipment pursuant to this section shall include two breast pump kits per birth event, as well as appropriate size breast pump flanges, or other lactation accessories recommended by a health care provider. (4) Breastfeeding equipment specified in paragraphs (1) and (3) of this subsection shall be furnished: within 48 hours of notification of need, if requested after the birth of the child; or by the later of two weeks before the enrollee's expected due date or 72 hours after notification, if requested prior to the birth of the child. If the enrollee does not receive breastfeeding equipment within 48 hours, the enrollee may purchase the equipment and the contract shall provide for reimbursement of all out-of-pocket expenses incurred by the enrollee, including any balance billing amounts. (5) Breastfeeding equipment specified in paragraph (2) of this subsection shall be made available within 12 hours of notification of need. If equipment is not available within 12 hours of notification of need, the contract shall provide for reimbursement of all out-of-pocket rental expenses incurred by the enrollee, including any balance billing amounts, until the enrollee receives breastfeeding equipment. c. Coverage of comprehensive lactation counseling and lactation consultation shall include: (1) In-person, one-on-one lactation counseling and lactation consultation, subject to the following conditions: (a) Coverage shall include visits that occur inside and outside a hospital or office setting. In-person lactation counseling and lactation consultation shall be covered regardless of location of service provision and shall include home visits. (b) Lactation counseling and lactation consultation shall be made available within 24 hours of notification of need. (2) Telephonic lactation assistance shall be covered in addition to, and not as a substitute for, in-person, one-on-one lactation counseling or lactation consultation, when an enrollee requests one-on-one, in-person lactation counseling or lactation consultation. The telephonic lactation assistance shall be provided within 12 hours of notification of need. (3) Group lactation counseling shall be covered in addition to, and not as a substitute for, one-on-one, in-person lactation counseling or lactation consultation, if an enrollee requests one-on-one, in-person lactation counseling or lactation consultation. Group counseling shall include educational classes and support groups. (4) A contract shall not require prior authorization, prescription or referral for any lactation counseling or lactation consultation, regardless of provider type or setting. (5) A contract shall not impose medical management techniques not described in this section. d. Except as otherwise authorized pursuant to this section, a contract shall not impose restrictions on the coverage provided pursuant to this section, including, but not limited to, limitations on reimbursement to allowable amounts or reasonable and customary charges, documentation requests, or delays on the coverage provided. e. As used in this section: "Cost-sharing" means deductible, co-insurance or co-payments, or similar charges. "Breast pump kit" means a collection of tubing, valves, flanges, collection bottles, or other parts required to extract human milk using a breast pump. "Lactation consultant" means an individual who is an International Board Certified Lactation Consultant. "Lactation consultation" means the clinical application by a lactation consultant or other licensed health care provider of scientific principles and a multidisciplinary body of evidence for evaluation, problem identification, treatment, education, and consultation to child-bearing families utilizing lactation care and services. Lactation care and services shall include, but not be limited to: (1) lactation assessment through the systematic collection of subjective and objective data; (2) analysis of data and creation of a plan of care; (3) implementation of a lactation care plan with demonstration and instruction to parents and communication to the primary health care provider; (4) evaluation of outcomes; (5) provision of lactation education to parents and health care providers; and (6) the recommendation and use of assistive devices. "Lactation counseling" means breastfeeding education and support services provided by a lactation counselor, such as: (1) educating women, families, health care professionals, and the community about the impact of breastfeeding and human lactation on health and what to expect in the normal course of breastfeeding; (2) acting as an advocate for breastfeeding as the norm for feeding infants and young children; (3) providing breastfeeding support, encouragement, and care from preconception to weaning in order to help women and their families meet their breastfeeding goals; (4) using principles of adult education when teaching clients, health care providers, and others in the community; and (5) identifying and referring high-risk mothers and babies and those requiring clinical treatment appropriately. "Lactation counselor" means an individual, other than an International Board Certified Lactation Consultant or a licensed health care provider, who is: (1) licensed or certified to practice lactation counseling under any law, or who is an accredited member belonging to another profession or occupation, who provides breastfeeding education and support services for which that person is licensed, regulated, accredited, or certified; or (2) a community-based lactation supporter who has received at least 40 hours of specialty education in breastfeeding and lactation, and who works within a lactation counselor's scope of practice. "Telephonic lactation assistance" means lactation counseling or consultation with a lactation counselor or lactation consultant conducted remotely through live voice communication. L.2019, c.343, s.9. 52:14-17.29dd SHBC to cover preventive services. 9. a. The State Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits shall provide coverage, without requiring any cost sharing, for the following preventive services: (1) evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force; (2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; (3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and (4) with respect to women, any additional preventive care and screenings not described in paragraph (1) as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. b. (1) Except as provided in paragraph (2) of this subsection, nothing in this section shall: (a) require a contract which has a network of providers to provide benefits for items or services described in subsection a. of this section that are delivered by an out-of-network provider; or (b) preclude a contract which has a network of providers from imposing cost-sharing requirements for items or services described in subsection a. of this section that are delivered by an out-of-network provider. (2) If a contract does not have in its network a provider who can provide an item or service described in subsection a. of this section, the contract shall cover the item or service when performed by an out-of-network provider, and shall not impose cost sharing with respect to that item or service. c. (1) A contract shall provide coverage for an item or service described in subsection a. of this section for plan years that begin on or after the date that is one year after the date the recommendation or guideline is issued. (2) (a) Except as provided in subparagraph (b) of this paragraph, a contract that is required to provide coverage for an item or service described in subsection a. of this section on the first day of a plan year shall provide coverage for that item or service through the last day of the plan year. (b) The commissioner may remove a coverage requirement for an item or service during a plan year if the recommendation or guideline changes or is no longer described in subsection a. of this section. L.2019, c.360, s.9. 52:14-17.29ee State Health Benefit Commission to cover adolescent depression screenings. 9. The State Health Benefits Commission shall ensure that every contract purchased by the commission, on or after the effective date of this act, that provides hospital or medical expense benefits shall provide coverage for expenses incurred in screening adolescents between the ages of 12 and 18 for major depressive disorder, so long as screening for major depressive disorder in adolescents continues to receive a rating of "A" or "B" from the United States Preventative Services Task Force. Coverage shall not be denied solely on the basis that the screening is provided in conjunction with any other health care evaluation, treatment, or service. The benefits shall be provided to the same extent as for any other condition under the contract, except that the contract shall not impose on covered persons receiving these services any form of cost sharing, including, but not limited to, copayments, deductibles, or coinsurance. L.2021, c.73, s.9. 52:14-17.29ff State Health Benefits Program, opioid antidote coverage. 3. a. Notwithstanding any law or regulation to the contrary, the State Health Benefits Commission and the School Employees' Health Benefits Commission shall ensure that every contract under the State Health Benefits Program shall provide coverage for an opioid antidote to eligible members of the State Health Benefits Program and the School Employees' Health Benefits Program. The coverage shall be provided without the imposition of any prior authorization or other utilization management requirements, provided that the treatment is: (1) prescribed or administered to the eligible member by a licensed medical practitioner who is authorized to prescribe or administer that treatment pursuant to State and federal law; or (2) dispensed to the eligible member by a licensed pharmacist under a standing order to dispense an opioid antidote pursuant to section 1 of P.L.2017, c.88 (C.45:14-67.2). b. The provisions of this section shall not be construed to limit the coverage of an opioid antidote only when administered by a medical practitioner. c. Each commission shall develop and issue guidelines to ensure the safety and efficacy of benefits provided pursuant to this section. d. As used in this section: "Opioid antidote" means naloxone hydrochloride, or any other similarly acting drug approved by the United States Food and Drug Administration for self-administration for the treatment of an opioid overdose. L.2021, c.157, s.3. 52:14-17.29gg SHBC to cover newborn home nurse visitation. 14. a. The State Health Benefits Commission shall provide benefits to each person covered under the State Health Benefits Program for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159). The benefits shall: (1) provide coverage for the services provided by the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159); (2) notify a covered person of the services provided by the newborn home nurse visitation program, upon application by the covered person for coverage of a newborn infant; (3) ensure that the plan does not contain any provision that requires a covered person to receive the services provided by the newborn home nurse visitation program as a condition of coverage, or that denies or limits benefits to the covered person if that person declines the services provided under the program; and (4) have the discretion to determine how best to reimburse for the expenses incurred for services provided under the newborn home nurse visitation program, including, but not limited to, utilizing: (a) a value-based payment methodology; (b) an invoice claim process; (c) a capitated payment arrangement; (d) a payment methodology that takes into account the need for an agency or organization providing services under the program to expand its capacity to provide services and address health disparities; or (e) any other payment arrangement agreed to by the carrier and an agency or organization providing services under the program. b. Any copayment, coinsurance, or deductible that may be required under the contract for such services shall be waived. c. The State Health Benefits Commission shall submit to the Department of Children and Families, in a form and manner prescribed by the department, a report on the claims submitted for services provided under the newborn home nurse visitation program. The information contained in the report shall be used by the department to assess the newborn home nurse visitation program pursuant to subsection a. of section 4 of P.L.2021, c.187 (C.26:2H-161). d. (1) Except as provided in paragraphs (2) and (3) of this subsection, the contract shall specify that no deductible, coinsurance, copayment, or any other cost-sharing requirement may be imposed on the coverage required pursuant to this section. (2) A contract provided by the State Health Benefits Commission that qualifies as a high deductible health plan shall provide benefits for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159) at the lowest deductible and other cost-sharing requirement permitted for a high deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223). (3) A contract provided by the State Health Benefits Commission that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, shall provide benefits for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159) at the lowest deductible and other cost-sharing requirement to the extent permitted for a catastrophic plan under federal law. e. The benefits shall be provided to the same extent as for any other medical condition under the contract. L.2021, c.187, s.14. 52:14-17.29hh SHBC, coverage for abortion, certain religious employers exemption. 4. A contract providing hospital or medical expense benefits purchased by the State Health Benefits Commission may provide coverage for abortion. A contract providing hospital or medical expense benefits purchased by the commission shall not exclude a provider from its network or otherwise restrict services from the provider solely on the basis that the provider is a religious employer, as defined in section 3 of P.L.2021, c.375 (C.26:2S-39), that refuses to provide abortion services. L.2021, c.375, s.4. 52:14-17.29ii Full-time firefighters to be screened for cancer. 1. a. A firefighter employed as a full-time paid employee of a fire department or unit of this State or a political subdivision of this State shall be provided a cancer screening examination conducted by a physician not less than three years after the start of the firefighter's employment as a firefighter and every three years thereafter during the course of the firefighter's employment. The examination shall include screening for, at a minimum and when applicable, the following cancers: (1) colon; (2) lung; (3) bladder; (4) oral; (5) thyroid; (6) skin; (7) blood; (8) breast; (9) cervical (10) testicular; and (11) prostate. b. Subsection a. of this section shall apply to a firefighter enrolled in the State Health Benefits Program as occupational coverage. For the purpose of this subsection, employment as a full-time paid employee of a fire department or unit of this State or a political subdivision of this State shall be a pre-existing condition. c. (1) Notwithstanding the provisions of any other law, rule, or regulation to the contrary, beginning January 1, 2023 and for each plan year thereafter, a public employer that does not participate in the State Health Benefits Program shall provide health care benefits coverage for its employees that offers cancer screening examinations consistent with the requirement of subsection a. of this section. A public employer that does not participate in the State Health Benefits Program shall be eligible for payment from the State for the cost of providing benefits coverage for such examinations upon proof satisfactory to the Department of the Treasury that the examination has been performed by a physician; provided, however, at no time shall the cost being remitted to the public employer by the State for the full examination required under subsection a. of this section exceed $1,250 per three-year period for each firefighter. (2) Notwithstanding the provisions of any other law, rule, or regulation to the contrary, beginning on the effective date of P.L.2024, c.15, a public employer that participates in the State Health Benefits Program shall provide coverage for cancer screening examinations consistent with the requirement of subsection a. of this section for an employee who is eligible for other health care coverage and waives coverage under the State Health Benefits Program to which the employee is entitled by virtue of employment with the employer. Such public employer shall be eligible for payment from the State for the cost of providing such examinations upon proof satisfactory to the Department of the Treasury that the examination has been performed by a physician; provided, however, at no time shall the cost being remitted to the public employer by the State for the full examination required under subsection a. of this section exceed $1,250 per three-year period for each firefighter. No co-payment, deductible, coinsurance, or out-of-pocket expense shall be required for such examinations. A public employer shall maintain adequate records to facilitate the reimbursement authorized pursuant to this subsection. For the purpose of this subsection, employment as a full-time paid employee of a fire department or unit of this State or a political subdivision of this State shall be a pre-existing condition. There shall be an appropriation from the State General Fund in each annual appropriations act of such funds as necessary for the purposes of this section. L.2021, c.478; amended 2022, c.109; 2024, c.15. 52:14-17.29jj State Health Benefits Commission, contract, provide coverage for colorectal cancer screening. 9. a. The State Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act, that provides hospital or medical expense benefits shall provide benefits to any person covered thereunder for expenses incurred in conducting a colorectal cancer screening in accordance with United States Preventive Services Task Force recommendations. The method and frequency of screening to be utilized shall be in accordance with the most recent published recommendations of the United States Preventive Services Task Force and as determined medically necessary by the covered person's physician, in consultation with the covered person. b. No deductible, coinsurance, copayment, or any other cost-sharing requirement shall be imposed for a colonoscopy performed following a positive result on a non-colonoscopy, colorectal cancer screening test recommended by the United States Preventive Services Task Force. c. The benefits shall be provided to the same extent as for any other medical condition under the contract. L.2023, c.8, s.9. 52:14-17.29kk State Health Benefits Commission, ensure, contract purchased, renewed, coverage, insulin for diabetes treatment. 25. The State Health Benefits Commission shall ensure that every contract purchased or renewed by the commission on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.), shall provide coverage for health care services to a person covered thereunder for insulin for the treatment of diabetes, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of a short-acting, intermediate-acting, rapid-acting, long-acting, and pre-mixed insulin product shall not be subject to any deductible, and no copayment or coinsurance for the purchase of insulin shall exceed $35 per 30-day supply, except a contract provided by the State Health Benefits Commission that qualifies as a high-deductible health plan shall provide coverage for the purchase of insulin at the lowest deductible and other cost-sharing requirement permitted for a high-deductible health plan under section 223(c)(2)(A) of the federal Internal Revenue Code (26 U.S.C. s.223 (c)(2)(A)). The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law. Nothing in this section shall prevent the State Health Benefits Commission from reducing an enrollee's cost-sharing requirement by an amount greater than the amount specified in this section or prevent the commission from utilizing formulary management, including a mandatory generic policy, to promote the use of lower-cost alternative generic drugs that are the therapeutic equivalent of the brand-name drug, which could result in the member's copay being higher than set forth in this section. L.2023, c.105, s.25. 52:14-17.29ll State Health Benefits Commission, ensure, contract purchased, renewed, coverage, epinephrine auto-injector device. 26. The State Health Benefits Commission shall ensure that every contract purchased or renewed by the commission on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.), shall provide coverage for at least one epinephrine auto-injector device, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of an epinephrine auto-injector device shall not be subject to any deductible, and no copayment or coinsurance for the purchase of an epinephrine auto-injector device shall exceed $25 per 30-day supply, except a contract provided by the State Health Benefits Commission that qualifies as a high-deductible health plan shall provide coverage for the purchase of an epinephrine auto-injector device at the lowest deductible and other cost-sharing requirement permitted for a high-deductible health plan under section 223(c)(2)(A) of the federal Internal Revenue Code (26 U.S.C. s.223 (c)(2)(A)). The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law. Nothing in this section shall prevent the State Health Benefits Commission from reducing a covered person's cost-sharing requirement by an amount greater than the amount specified in this section or prevent the commission from utilizing formulary management, including a mandatory generic policy, to promote the use of lower-cost alternative generic drugs that are the therapeutic equivalent of the brand-name drug, which could result in the member's copay being higher than set forth in this section. L.2023, c.105, s.26. 52:14-17.29mm State Health Benefits Commission, ensure, contract purchased, renewed, coverage, prescription asthma inhaler. 27. The State Health Benefits Commission shall ensure that every contract purchased or renewed by the commission on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.), shall provide benefits to a person covered thereunder for expenses incurred for a prescription asthma inhaler, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of a covered prescription asthma inhaler shall not be subject to any deductible, and no copayment or coinsurance for the purchase of a covered prescription asthma inhaler shall exceed $50 per 30-day supply, except a contract provided by the State Health Benefits Commission that qualifies as a high-deductible health plan shall provide coverage for the purchase of a covered prescription asthma inhaler at the lowest deductible and other cost-sharing requirement permitted for a high-deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223). The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law. Nothing in this section shall prevent the State Health Benefits Commission from reducing a covered person's cost-sharing requirement by an amount greater than the amount specified in this section or prevent the commission from utilizing formulary management, including a mandatory generic policy, to promote the use of lower-cost alternative generic drugs that are the therapeutic equivalent of the brand-name drug, which could result in the member's copay being higher than set forth in this section. L.2023, c.105, s.27. 52:14-17.29nn Biomarker precision medical testing coverage, State Health Benefits Commission contracts. 9. a. The State Health Benefits Commission shall ensure that every contract providing hospital or medical expense benefits, which is purchased by the commission on or after the effective date of this act, provides coverage for biomarker precision medical testing, as defined by subsection e. of this section. b. Biomarker precision medical testing shall be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of a disease or condition, excluding asymptomatic screening, to guide treatment decisions of a covered person when the efficacy and appropriateness of biomarker precision medical testing for the diagnosis, treatment, appropriate management, or guiding treatment decisions for a covered person's disease or condition is recognized by: (1) labeled indications for an FDA-approved or -cleared test; (2) indicated tests for an FDA-approved drug; (3) actions to address warnings and precautions on FDA-approved drug labels; (4) Centers for Medicare and Medicaid Services National Coverage Determinations or Medicare Administrative Contractor Local Coverage Determinations; or (5) nationally recognized clinical practice guidelines. c. Coverage, pursuant to subsection b. of this section, shall be provided in a manner that limits disruption, including multiple biopsies or biospecimen samples, in the care of a covered person. d. (1) If utilization review is required, a decision shall be rendered pursuant to the guidelines and timeframes set forth in P.L.2023, c.296 (C.17B:30-55.1 et al.). (2) The covered person and the treating health care provider or treating health care entity prescribing biomarker precision medical testing to the covered person shall have access to clear, readily accessible, and conspicuous information on the process to submit an appeal to an adverse determination. e. As used in this section: "Biomarker" means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention, including known gene-drug interactions for medications being considered for use or already being administered. Biomarkers shall also include, but not be limited to, gene mutations, characteristics of genes, or protein expression. "Biomarker precision medical testing" means the analysis of tissue, blood, or other biospecimen for the presence of a biomarker. Biomarker precision medical testing includes, but is not limited to, single-analyte tests, multiplex panel tests, protein expression, and whole exome, whole genome, and whole transcriptome sequencing. "Nationally recognized clinical practice guidelines" means evidence-based clinical practice guidelines developed by independent organizations or medical professional societies utilizing a transparent methodology and reporting structure and with a conflict of interest policy. The guidelines establish standards of care informed by a systematic review of evidence and an assessment of the benefits and risks of alternative care options and include recommendations intended to optimize patient care. L.2025, c.49, s.9. 52:14-17.29oo State Health Benefits Commission, HIV preexposure prophylaxis, HIV postexposure 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.2025, c.196 (C.45:14-67.13) without requiring prior authorization or step therapy. (2) If the federal Food and Drug Administration has authorized or 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.2025, c.196 (C.45:14-67.13) in excess of a 90-day 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.2025, c.196 (C.45:14-67.12). �HIV postexposure prophylaxis� means the same as that term is defined in section 1 of P.L.2025, c.196 (C.45:14-67.12). �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. L.2025, c.196, s.12. 52:14-17.29pp Benefits provided under contracts purchased by the State Health Benefits Commission. 9. a. The State Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of P.L.2025, c.200 (C. 17:48-6bbb et al.), that provides hospital or medical expense benefits shall provide benefits to any person covered thereunder for expenses incurred in obtaining medically necessary treatment for women with a diagnosis of perimenopause, menopause, and symptoms associated with perimenopause and menopause, including, but not limited to: (1) hormonal therapies such as hormone replacement therapy and bioidentical hormone treatments; (2) non-hormonal treatments, including medications to manage menopausal symptoms; (3) behavioral health care services; (4) pelvic floor physical therapy; (5) bone health treatments, including screenings and medications due to hormonal changes related to perimenopause and menopause; (6) preventative services that have a rating of �A� or �B� in the current recommendations of the United States Preventive Services Task Force for early detection and treatment of health conditions related to perimenopause and menopause such as osteoporosis and cancer; and (7) counseling and education regarding menopause management. b. The State Health Benefits Commission shall ensure that each contract shall provide clear and accessible information to a covered person regarding covered perimenopause and menopause treatments. c. The benefits shall be provided to the same extent as for any other medical condition under the contract. d. As used in this section: �Menopause� means the permanent end of a female�s menstrual cycle, diagnosed by a licensed medical provider after 12 consecutive months without a menstrual period. �Perimenopause� means the transitional period leading to menopause, marked by fluctuating hormone levels and changes in menstrual cycles. L.2025, c.200, s.9.

This is the verbatim text of N.J.S.A. 52:14-17.29z, 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.