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Code · New Jersey · Title 17B — Insurance · Chapter 27F

17B:27F-3.4 Carrier, use of pharmacy benefits manager, administer, manage, prescription drug benefits, claims, parameters.

248 words·~1 min read·/nj/title-17b/chapter-27f/17b-27f-3-4·

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

9. a. If a carrier uses a pharmacy benefits manager to administer or manage the prescription drug benefits of covered persons, any pharmacy benefits manager compensation, for purposes of calculating a carrier's anticipated loss ratio or any loss ratio calculated as part of any applicable medical loss ratio filing or rate filing, shall:
(1)constitute an administrative cost incurred by the carrier in connection with a health benefits plan; and
(2)not constitute a benefit provided under a health benefits plan. A carrier shall claim only the amounts paid by the pharmacy benefits manager to a pharmacy or pharmacist as an incurred claim.
b. Any rate filing submitted by a carrier with respect to a health benefits plan that provides coverage for prescription drugs or pharmacy services and that is administered or managed by a pharmacy benefits manager shall include:
(1)a memorandum prepared by a qualified actuary describing the calculation of the pharmacy benefits manager compensation; and
(2)any records and supporting information as the department reasonably determines is necessary to confirm the calculation of the pharmacy benefits manager compensation.
c. Upon request, a carrier shall provide any records to the department that relate to the calculation of the pharmacy benefits manager and pharmacy services administrative organization compensation.
d. A pharmacy benefits manager and pharmacy services administrative organization shall provide any necessary documentation requested by a carrier that relates to pharmacy benefits manager compensation in order to comply with the requirements of this section.
L.2023, c.107, s.9.
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