A 5317

ASSEMBLY, No. 5317
STATE OF NEW JERSEY
222nd LEGISLATURE
�
INTRODUCED JUNE 23, 2026
Sponsored by:
DOAssemblywoman� MARGIE DONLON, M.D.
District 11 (Monmouth)
SYNOPSIS
���� Requires health insurance carriers to provide
opportunity to clinical laboratory and laboratory services provider to
participate as preferred or contracting provider in carriers� provider network.
CURRENT VERSION OF TEXT
���� As introduced.
��
An Act concerning provider networks and amending
P.L.1993, c.378.
���� Be It
Enacted by the Senate and General Assembly of
the State of New Jersey:
���� 1.��� Section 1 of P.L.1993,
c.378 (C.17:48-6j) is amended to read as follows:
���� 1.��� a. �Notwithstanding any
other provision of law to the contrary, no group or individual hospital 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, clinical
laboratory, or laboratory services provider for the provision of
prescription drugs or pharmacy services, clinical laboratory services, or
laboratory services, provided that:
���� (a)�� any pharmacist or
pharmacy selected by the subscriber is registered pursuant to R.S.45:14-1 et
seq.; and
���� (b)�� any clinical
laboratory selected by the subscriber is licensed pursuant to the �New Jersey
Clinical Laboratory Improvement Act,� P.L.1975, c.166 (C.45:9-42.26) or
certified pursuant to the federal �Clinical Laboratory Improvement Amendments
of 1988,� Pub.L.100-578 (42 U.S.C. s.263a);
���� (2)�� Provides that no
pharmacy or pharmacist, clinical laboratory, or laboratory services provider
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,
clinical laboratory services, or laboratory services, provided:
���� (a)�� the pharmacy or
pharmacist is registered pursuant to R.S.45:14-1 et seq., and accepts the terms
and conditions of the contract; and
���� (b)�� a clinical laboratory
is licensed pursuant to the �New Jersey Clinical Laboratory Improvement Act,�
P.L.1975, c.166 (C.45:9-42.26) or certified pursuant to the federal �Clinical
Laboratory Improvement Amendments of 1988,� Pub.L.100-578 (42 U.S.C. s.263a), 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, clinical laboratory,
or laboratory services provider that is not also equally imposed upon all
subscribers selecting a participating or contracting pharmacist or pharmacy,
clinical laboratory, or laboratory services provider;
���� (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 hospital service corporation and includes a
provision that any audit shall take place at a time mutually agreeable to the
pharmacy or pharmacist, clinical laboratory, or laboratory services provider
and the auditor.� No audit by a hospital service corporation shall include a
review of any document relating to any person or prescription plan other than
those reimbursable by the hospital service corporation; and
���� (6)�� Provides that the
hospital 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 hospital service corporation contracts in which the hospital
service corporation has reserved the right to change the subscriber charge.
���� d.��� A hospital service
corporation that offers a managed care plan, or an organized delivery system
contracting with the hospital service corporation, shall:
���� (1)�� not discriminate
against or exclude a willing pharmacy, pharmacist, clinical laboratory, or
laboratory services provider on the basis of corporate structure, size,
location, or affiliation, provided that the provider meets the hospital service
corporation credentialing standards and agrees to the reimbursement schedule
and performance criteria applicable to participating providers;
���� (2) upon request, provide
written notice of participation requirements, credentialing criteria,
reimbursement terms, and application procedures to a pharmacy, pharmacist,
clinical laboratory, or laboratory services provider.� A hospital service
corporation shall respond to a completed application for participation within
60 days of receipt; and
���� (3)�� issue a written
notice of denial, if a pharmacy, pharmacist, clinical laboratory, or laboratory
services provider is denied participation in a network, stating the specific
criteria that were not satisfied and informing the provider of the process for
reconsideration.
���� e.���� Nothing in this section
shall be construed to prohibit a hospital service corporation from establishing
quality, safety, utilization, or performance standards for participation in its
network, provided that the standards are applied in a uniform and
nondiscriminatory manner.
���� f.���� As used in this
section:
���� �Laboratory services
provider� means any person or entity that performs, directs, supervises, or
provides clinical laboratory services.
(cf: P.L.1999, c.395, s.1)
���� 2.��� Section 2 of P.L.1993,
c.378 (C.17:48A-7i) is amended to read as follows:
���� 2.��� a.� Notwithstanding any
other provision of law to the contrary, no group or individual medical 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
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, clinical
laboratory, or laboratory services provider for the provision of
prescription drugs or pharmacy services, clinical laboratory services, or
laboratory services, provided that:
���� (a)�� any pharmacist or
pharmacy selected by the subscriber is registered pursuant to R.S.45:14-1 et
seq.; or
���� (b)�� any clinical
laboratory selected by the subscriber is licensed pursuant to the �New Jersey
Clinical Laboratory Improvement Act,� P.L.1975, c.166 (C.45:9-42.26) or
certified pursuant to the federal �Clinical Laboratory Improvement Amendments
of 1988,� Pub.L.100-578 (42 U.S.C. s.263a);
���� (2)�� Provides that no
pharmacy or pharmacist, clinical laboratory, or laboratory services provider
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, clinical
laboratory services, or laboratory services, provided:
���� (a)�� the pharmacy or
pharmacist is registered pursuant to R.S.45:14-1 et seq., and accepts the terms
and conditions of the contract; or
���� (b)�� a clinical laboratory
is licensed pursuant to the �New Jersey Clinical Laboratory Improvement Act,�
P.L.1975, c.166 (C.45:9-42.26) or certified pursuant to the federal �Clinical
Laboratory Improvement Amendments of 1988,� Pub.L.100-578 (42 U.S.C. s.263a), 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, clinical laboratory,
or laboratory services provider that is not also equally imposed upon all
subscribers selecting a participating or contracting pharmacist or pharmacy,
clinical laboratory, or laboratory services provider;
���� (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 medical service corporation and includes a
provision that any audit shall take place at a time mutually agreeable to the
pharmacy or pharmacist, clinical laboratory, or laboratory services provider
and the auditor.� No audit by a medical service corporation shall include a
review of any document relating to any person or prescription plan other than
those reimbursable by the medical service corporation; and
���� (6)�� Provides that the
medical 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 medical service corporation contracts in which the medical service
corporation has reserved the right to change the subscriber charge.
���� d.��� A medical service
corporation that offers a managed care plan, or an organized delivery system
contracting with the medical service corporation, shall:
���� (1)�� not discriminate
against or exclude a willing pharmacy, pharmacist, clinical laboratory, or
laboratory services provider on the basis of corporate structure, size,
location, or affiliation, provided that the provider meets the medical service
corporation�s credentialing standards and agrees to the reimbursement schedule
and performance criteria applicable to participating providers;
���� (2) upon request, provide
written notice of participation requirements, credentialing criteria,
reimbursement terms, and application procedures to a pharmacy, pharmacist,
clinical laboratory, or laboratory services provider.� A medical service
corporation shall respond to a completed application for participation within
60 days of receipt; and
���� (3)�� issue a written
notice of denial, if a pharmacy, pharmacist, clinical laboratory, or laboratory
services provider is denied participation in a network, stating the specific
criteria that were not satisfied and informing the provider of the process for
reconsideration.
���� e.���� Nothing in this
section shall be construed to prohibit a medical service corporation from
establishing quality, safety, utilization, or performance standards for
participation in its network, provided that the standards are applied in a
uniform and nondiscriminatory manner.
���� f.���� As used in this
section:
���� �Laboratory services
provider� means any person or entity that performs, directs, supervises, or
provides clinical laboratory services.
(cf: P.L.1999, c.352, s.2)
���� 3.��� Section 3 of P.L.1993,
c.378 (C.17:48E-35.7) is amended to read as follows:
���� 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, clinical
laboratory, and laboratory services provider for the provision of
prescription drugs or pharmacy services, clinical laboratory services, or
laboratory services, provided that:
���� (a)�� any pharmacist or
pharmacy selected by the subscriber is registered pursuant to R.S.45:14-1 et
seq.; or
���� (b)�� any clinical
laboratory selected by the subscriber is licensed pursuant to the �New Jersey
Clinical Laboratory Improvement Act,� P.L.1975, c.166 (C.45:9-42.26) or
certified pursuant to the federal �Clinical Laboratory Improvement Amendments
of 1988,� Pub.L.100-578 (42 U.S.C. s.263a);
���� (2)�� Provides that no
pharmacy or pharmacist, clinical laboratory, or laboratory services provider
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, clinical
laboratory services, or laboratory services, provided:
���� (a)�� the pharmacy or
pharmacist is registered pursuant to R.S.45:14-1 et seq., and accepts the terms
and conditions of the contract; or
���� (b)�� a clinical laboratory
is licensed pursuant to the �New Jersey Clinical Laboratory Improvement Act,�
P.L.1975, c.166 (C.45:9-42.26) or certified pursuant to the federal �Clinical
Laboratory Improvement Amendments of 1988,� Pub.L.100-578 (42 U.S.C. s.263a),
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, clinical laboratory,
or laboratory services provider that is not also equally imposed upon all
subscribers selecting a participating or contracting pharmacist or pharmacy,
clinical laboratory, or laboratory services provider;
���� (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, clinical laboratory, or laboratory services provider
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; and
���� (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.
���� d.��� A health service
corporation that offers a managed care plan, or an organized delivery system
contracting with the health service corporation, shall:
���� (1)�� not discriminate
against or exclude a willing pharmacy, pharmacist, clinical laboratory, or
laboratory services provider on the basis of corporate structure, size,
location, or affiliation, provided that the provider meets the health service
corporation�s credentialing standards and agrees to the reimbursement schedule
and performance criteria applicable to participating providers;
���� (2) upon request, provide
written notice of participation requirements, credentialing criteria,
reimbursement terms, and application procedures to a pharmacy, pharmacist,
clinical laboratory, or laboratory services provider.� A health service
corporation shall respond to a completed application for participation within
60 days of receipt; and
���� (3)�� issue a written
notice of denial, if a pharmacy, pharmacist, clinical laboratory, or laboratory
services provider is denied participation in a network, stating the specific
criteria that were not satisfied and informing the provider of the process for
reconsideration.
���� e.���� Nothing in this
section shall be construed to prohibit a health service corporation from
establishing quality, safety, utilization, or performance standards for
participation in its network, provided that the standards are applied in a
uniform and nondiscriminatory manner.
���� f.���� As used in this
section:
���� �Laboratory services
provider� means any person or entity that performs, directs, supervises, or
provides clinical laboratory services.
(cf: P.L.1999, c.395, s.3)
���� 4.��� Section 4 of P.L.1993,
c.378 (C.17B:26-2.1i) is amended to read as follows:
���� 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, clinical laboratory, and
laboratory services provider for the provision of prescription drugs or
pharmacy services, clinical laboratory services, or laboratory services,
provided that:
���� (a)�� any pharmacist or
pharmacy selected by the insured is registered pursuant to R.S.45:14-1 et seq.;
or
���� (b)�� any clinical
laboratory selected by the insured is licensed pursuant to the �New Jersey
Clinical Laboratory Improvement Act,� P.L.1975, c.166 (C.45:9-42.26) or
certified pursuant to the federal �Clinical Laboratory Improvement Amendments
of 1988,� Pub.L.100-578 (42 U.S.C. s.263a);
���� (2)�� Provides that no
pharmacy or pharmacist, clinical laboratory, or laboratory services provider
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, clinical
laboratory services, or laboratory services, provided:
���� (a)�� the pharmacy or
pharmacist is registered pursuant to R.S.45:14-1 et seq., and accepts the terms
and conditions of the contract; or
���� (b)�� a clinical laboratory
is licensed pursuant to the �New Jersey Clinical Laboratory Improvement Act,�
P.L.1975, c.166 (C.45:9-42.26) or certified pursuant to the federal �Clinical
Laboratory Improvement Amendments of 1988,� Pub.L.100-578 (42 U.S.C. s.263a),
and accepts the terms and conditions of the contract;
���� (3)�� Provides that no
copayment, fee, or other condition shall be imposed upon an insured selecting a
participating or contracting pharmacist or pharmacy, clinical laboratory, or
laboratory services provider that is not also equally imposed upon all insureds
selecting a participating or contracting pharmacist or pharmacy, clinical
laboratory, or laboratory services provider;
���� (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,
clinical laboratory, or laboratory services provider 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; and
���� (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.
���� d.��� An insurer that
offers a managed care plan, or an organized delivery system contracting with
the insurer, shall:
���� (1)�� not discriminate
against or exclude a willing pharmacy, pharmacist, clinical laboratory, or
laboratory services provider on the basis of corporate structure, size,
location, or affiliation, provided that the provider meets the insurer�s credentialing
standards and agrees to the reimbursement schedule and performance criteria
applicable to participating providers;
���� (2) upon request, provide
written notice of participation requirements, credentialing criteria,
reimbursement terms, and application procedures to a pharmacy, pharmacist,
clinical laboratory, or laboratory services provider.� An insurer shall respond
to a completed application for participation within 60 days of receipt; and
���� (3)�� issue a written
notice of denial, if a pharmacy, pharmacist, clinical laboratory, or laboratory
services provider is denied participation in a network, stating the specific
criteria that were not satisfied and informing the provider of the process for
reconsideration.
���� e.���� Nothing in this
section shall be construed to prohibit an insurer from establishing quality,
safety, utilization, or performance standards for participation in its network,
provided that the standards are applied in a uniform and nondiscriminatory
manner.
���� f.���� As used in this
section:
���� �Laboratory services
provider� means any person or entity that performs, directs, supervises, or
provides clinical laboratory services.
(cf: P.L.1999, c.395, s.4)
���� 5.��� Section 5 of P.L.1993,
c.378 (C.17B:27-46.1i) is amended to read as follows:
���� 5.��� a.� Notwithstanding any
other provision of law to the contrary, no group 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, clinical laboratory, and
laboratory services provider for the provision of prescription drugs or
pharmacy services, clinical laboratory services, or laboratory services,
provided that:
���� (a)�� any pharmacist or
pharmacy selected by the insured is registered pursuant to R.S.45:14-1 et seq.;
or
���� (b)�� any clinical
laboratory selected by the insured is licensed pursuant to the �New Jersey
Clinical Laboratory Improvement Act,� P.L.1975, c.166 (C.45:9-42.26) or
certified pursuant to the federal �Clinical Laboratory Improvement Amendments
of 1988,� Pub.L.100-578 (42 U.S.C. s.263a);
���� (2)�� Provides that no
pharmacy or pharmacist, clinical laboratory, or laboratory services provider
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, clinical
laboratory services, or laboratory services, provided:
���� (a) the pharmacy or
pharmacist is registered pursuant to R.S.45:14-1 et seq., and accepts the terms
and conditions of the policy; or
���� (b)�� a clinical laboratory
is licensed pursuant to the �New Jersey Clinical Laboratory Improvement Act,�
P.L.1975, c.166 (C.45:9-42.26) or certified pursuant to the federal �Clinical
Laboratory Improvement Amendments of 1988,� Pub.L.100-578 (42 U.S.C. s.263a),
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, clinical laboratory, or
laboratory services provider that is not also equally imposed upon all
insureds selecting a participating or contracting pharmacist or pharmacy,
clinical laboratory, or laboratory services provider;
���� (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,
clinical laboratory, or laboratory services provider 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; and
���� (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 group health insurance policies in which the insurer has reserved
the right to change the premium.
���� d.��� An insurer that
offers a managed care plan, or an organized delivery system contracting with
the insurer, shall:
���� (1)�� not discriminate
against or exclude a willing pharmacy, pharmacist, clinical laboratory, or
laboratory services provider on the basis of corporate structure, size,
location, or affiliation, provided that the provider meets the insurer�s credentialing
standards and agrees to the reimbursement schedule and performance criteria
applicable to participating providers;
���� (2) upon request, provide
written notice of participation requirements, credentialing criteria,
reimbursement terms, and application procedures to a pharmacy, pharmacist,
clinical laboratory, or laboratory services provider.� An insurer shall respond
to a completed application for participation within 60 days of receipt; and
���� (3)�� issue a written
notice of denial, if a pharmacy, pharmacist, clinical laboratory, or laboratory
services provider is denied participation in a network, stating the specific
criteria that were not satisfied and informing the provider of the process for
reconsideration.
���� e.���� Nothing in this
section shall be construed to prohibit an insurer from establishing quality,
safety, utilization, or performance standards for participation in its network,
provided that the standards are applied in a uniform and nondiscriminatory
manner.
���� f.���� As used in this
section:
���� �Laboratory services
provider� means any person or entity that performs, directs, supervises, or
provides clinical laboratory services.
(cf: P.L.1999, c.395, s.5)
���� 6.��� Section 6 of P.L.1993,
c.378 (C.26:2J-4.7) is amended to read as follows:
���� 6.��� a. Notwithstanding any
provision of law to the contrary, a certificate of authority to establish and
operate a health maintenance organization in this State shall not be issued or
continued [on
or after the effective date of this act]
for a health maintenance organization which provides pharmacy services,
prescription drugs, or a prescription drug plan, unless the coverage for health
care services:
���� (1)�� Permits the enrollee, at
the time of enrollment, to select benefit coverage allowing the enrollee to
choose a pharmacy or pharmacist, clinical laboratory, or laboratory services
provider for the provision of prescription drugs or pharmacy services, clinical
laboratory services, or laboratory services, provided that:
���� (a)�� any pharmacist or
pharmacy selected by the enrollee is registered pursuant to R.S.45:14-1 et
seq.; or
���� (b)�� any clinical
laboratory selected by the enrollee is licensed pursuant to the �New Jersey
Clinical Laboratory Improvement Act,� P.L.1975, c.166 (C.45:9-42.26) or
certified pursuant to the federal �Clinical Laboratory Improvement Amendments
of 1988,� Pub.L.100-578 (42 U.S.C. s.263a);
���� (2)�� Provides that no
pharmacy or pharmacist, clinical laboratory, or laboratory services provider
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 health maintenance
organization provides for coverage by contracted or preferred providers for
pharmaceutical services, clinical laboratory services, or laboratory
services, provided:
���� (a)�� the pharmacy or
pharmacist is registered pursuant to R.S.45:14-1 et seq., and accepts the terms
and conditions of the health maintenance organization; or
���� (b)�� a clinical laboratory
is licensed pursuant to the �New Jersey Clinical Laboratory Improvement Act,�
P.L.1975, c.166 (C.45:9-42.26) or certified pursuant to the federal �Clinical
Laboratory Improvement Amendments of 1988,� Pub.L.100-578 (42 U.S.C. s.263a), and
accepts the terms and conditions of the health maintenance organization;
���� (3)�� Provides that no
copayment, fee, or other condition shall be imposed upon an enrollee selecting
a participating or contracting pharmacist or pharmacy, clinical laboratory,
or laboratory services provider that is not also equally imposed upon all
enrollees selecting a participating or contracting pharmacist or pharmacy,
clinical laboratory, or laboratory services provider;
���� (4) (a) Provides that no
enrollee 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 except for any health care-related programs funded in
whole or in part with State funds, including, but not limited to, the Medicaid
program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.) and the
"Children's Health Care Coverage Program" established pursuant to
P.L.1997, c.272 (C.30:4I-1 et seq.);
���� (5)�� Sets forth the auditing
procedures to be used by the health maintenance organization and includes a
provision that any audit shall take place at a time mutually agreeable to the
pharmacy or pharmacist, clinical laboratory, or laboratory services provider
and the auditor, unless authorized by the Division of Medical Assistance and
Health Services in the Department of Human Services with regard to any health
care-related programs funded in whole or in part with State funds, including,
but not limited to, the Medicaid program and "Children's Health Care
Coverage Program".� No audit by a health maintenance organization shall
include a review of any document relating to any person or prescription plan
other than those reimbursable by the health maintenance organization, unless
authorized by the Division of Medical Assistance and Health Services in the
Department of Human Services with regard to any health care-related programs
funded in whole or in part with State funds, including, but not limited to, the
Medicaid program and "Children's Health Care Coverage Program"; and
���� (6)�� Provides that the health
maintenance organization, or any agent or intermediary thereof, including a
third party administrator, shall not restrict or prohibit, directly or
indirectly, a pharmacy from charging the enrollee 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 the Division of Medical Assistance and Health Services in the
Department of Human Services or State or federal law[;
���� (7)�� The provisions of
P.L.1999, c.395 shall apply to all health maintenance organization 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 coverage for health care services, to
increase the scope of any coverage for health care services, or to increase the
level of any health care services provided by a health maintenance organization.
���� c.���� This section shall
apply to health maintenance organization plans in which the right to change the
enrollee charge has been reserved.
���� d.��� A health maintenance
organization that offers a managed care plan, or an organized delivery system
contracting with the health maintenance organization, shall:
���� (1)�� not discriminate
against or exclude a willing pharmacy, pharmacist, clinical laboratory, or
laboratory services provider on the basis of corporate structure, size,
location, or affiliation, provided that the provider meets the health
maintenance organization�s credentialing standards and agrees to the
reimbursement schedule and performance criteria applicable to participating
providers;
���� (2) �upon request, provide
written notice of participation requirements, credentialing criteria,
reimbursement terms, and application procedures to a pharmacy, pharmacist,
clinical laboratory, or laboratory services provider.� A health maintenance
organization shall respond to a completed application for participation within
60 days of receipt; and
���� (3)�� issue a written
notice of denial, if a pharmacy, pharmacist, clinical laboratory, or laboratory
services provider is denied participation in a network, stating the specific
criteria that were not satisfied and informing the provider of the process for
reconsideration.
���� e.���� Nothing in this
section shall be construed to prohibit a health maintenance organization from
establishing quality, safety, utilization, or performance standards for
participation in its network, provided that the standards are applied in a
uniform and nondiscriminatory manner.
���� f.���� As used in this
section:
���� �Laboratory services
provider� means any person or entity that performs, directs, supervises, or
provides clinical laboratory services.
(cf: P.L.1999, c.395, s.6)
���� 7.��� The Commissioner of
Banking and Insurance shall adopt rules and regulations, pursuant to the
�Administrative Procedure Act,� P.L.1968, c.140 (C.52:14B-1 et seq.), as may be
necessary to effectuate the provisions of this act.
���� 8.��� This act shall take
effect on the first day of the seventh month next after the date of enactment
and shall apply to policies and contracts issued or renewed on or after that
date, except that the commissioner may take any anticipatory administrative
action in advance as shall be necessary for the implementation of this act.
STATEMENT
���� This bill amends current law
by requiring a health insurance carrier (a hospital service corporation,
medical service corporation, group and individual insurers, and a health
maintenance organization) to extend the same opportunity currently allowed
pharmacies and pharmacists to participate as a preferred provider or as a
contracting provider in a health benefits plan to clinical laboratories and
laboratory services providers.
���� Under the bill, a carrier that
offers a managed care plan, or an organized delivery system contracting with a
carrier, is to not discriminate against or exclude a willing pharmacy practice
site, pharmacist, clinical laboratory, or laboratory services provider on the
basis of corporate structure, size, location, or affiliation, provided that the
provider meets the carrier�s credentialing standards and agrees to the
reimbursement schedule and performance criteria applicable to participating
providers.� A carrier, upon request, is to provide written notice of provider
participation requirements, credentialing criteria, reimbursement terms, and
application procedures to a pharmacy practice site, pharmacist, clinical
laboratory, or laboratory services provider.� A carrier is to respond to a
completed application for participation within 60 days of receipt.� A carrier
that denies participation to a provider is to issue a written notice of denial
stating the specific criteria that were not satisfied and informing the
provider of the process for reconsideration.
���� Nothing in the bill is to be
construed as prohibiting a carrier from establishing quality, safety,
utilization, or performance standards for participation in its network,
provided that the standards are applied in a uniform and nondiscriminatory
manner.