17B:27A-7.35 Individual health benefits plan, HIV preexposure prophylaxis, HIV postexposure prophylaxis.
519 words·~2 min read·
/nj/title-17b/chapter-27a/17b-27a-7-35·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
8. a.
(1)Except as provided in paragraph
(2)of this subsection, every individual health benefits plan that is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.) or approved for issuance or renewal in this State, on or after the effective date of this act, shall provide benefits to any person covered thereunder 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 plan 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. Reimbursement issued under this section to a pharmacist shall be at a rate that is no less than the rate provided by the individual health benefits plan to other non-physician practitioners if the reimbursement is for a service or procedure that meets the following criteria:
(1)the service or procedure is within the scope of practice of the treating pharmacist; and
(2)the service or procedure would otherwise be covered under the plan if provided by a healthcare provider, including a physician, advanced practice nurse, or physician assistant.
c. An individual health benefits plan shall grant a licensed pharmacist receiving reimbursement under this section the same rights of participation, plan admission, and registration as may be granted by the plan to a healthcare provider, including a physician, advanced practice nurse, or physician assistant, who is reimbursed for an identical service.
d.An individual health benefits plan 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.
e. Nothing in this section shall be construed to require an individual health benefit plan 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.
f. The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.
g. 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.8.