On December 19, 2016, the Commissioner of the New Jersey Department of Banking and Insurance, Richard J. Badolato, issued Bulletin No. 16-12 to all health service corporations, hospital service corporations, medical service corporations, health insurance companies, and health maintenance organizations with respect to implementation of a law enacted in January of 2016. See P.L. 2015, c. 206 (Chapter 206). Chapter 206 requires that all carriers, the state health benefits plan and the school employees’ health benefits plan which provide benefits for pharmacy services, prescription drugs or prescription drug plans take certain steps with respect to member sharing, including:
1. applying a prorated daily cost-sharing rate, i.e., co-payment, to prescriptions that are dispensed by a network pharmacy for less than a 30-day supply if the prescriber or pharmacist indicates the fill or refill is in the best interest of the covered person or is for the purpose of synchronizing the covered person’s chronic medication;
2. providing coverage for a drug prescribed for the treatment of chronic illness dispensed in accordance with a plan developed by the covered person, the prescriber and the pharmacist to synchronize the refilling of multiple prescriptions for the covered person; and
3. determining dispensing fees based solely on the total number of prescriptions dispensed; although member cost-sharing is prorated, dispensing fees cannot be prorated.
These requirements do not apply to certain drug classes, including opioid analgesics.
The Department’s Bulletin includes helpful examples with respect to prorating and synchronization of drug therapy. A copy of the Department’s Bulletin is linked below.