26:2J-4.52 Certificate of authority to establish and operate a health maintenance organization, HIV preexposure prophylaxis, HIV postexposure prophylaxis.
522 words·~2 min read·
/nj/title-26/chapter-2j/26-2j-4-52·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
10. a.
(1)Except as provided in paragraph
(2)of this subsection, 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 by the Commissioner of Banking and Insurance on or after the effective date of this act unless the health maintenance organization provides health care services to any enrollee 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 health maintenance organization 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 by the health maintenance organization if provided by a healthcare provider, including a physician, advanced practice nurse, or physician assistant.
c. A health maintenance organization 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 health maintenance organization to a healthcare provider, including a physician, advanced practice nurse, or physician assistant, who is reimbursed for an identical service.
d.A health maintenance organization 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 a health maintenance organization 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 benefits shall be provided to the same extent as for any other medical condition under the contract.
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.10.