Breaking News – New Jersey PBM Retroactive Fee Bill (S728/A3717) in Commercial Plans Becomes Law!
S728/A3717 Retains all the Original Protections Approved by the Legislature in Non-ERISA Commercial Plans – Covers 30 Percent of the Insured Lives
- Prohibits Retroactive Fees: The bill specifically prohibits retroactive fees in commercial plans and requires that all fees be charged at the point-of-sale. When a pharmacy adjudicates a claim at the point of sale, the reimbursement amount provided to the pharmacy by the PBM shall constitute a final reimbursement amount.
- Strengthens the State MAC Law: When the bill is enacted, brand effective rate, generic effective rate, professional fee, any successive pricing formulas and any other pricing methodology utilized by the PBM in commercial plans will be specifically listed in the MAC law.
- Strengthens Appeals Process: If the appeal is denied, PBMs must provide the name of wholesalers from which the appealing pharmacy can obtain the drug at or below the brand effective rate, generic effective rate, dispensing fee effective rate, maximum allowable cost or any other pricing formula for pharmacy reimbursement.
- Mailing of Prescriptions: A pharmacy licensed in the State of New Jersey shall be permitted to make product deliveries and mail prescriptions to patients in commercial plans without contractual restrictions by a pharmacy benefits manager.
- Approve Compensation: The Commissioner of Banking and Insurance may review and approve the compensation program of a pharmacy benefits manager in commercial health benefits plan to ensure that the reimbursement for pharmacist services paid to a pharmacy is fair and reasonable.
NJ Board of Pharmacy USP 800 Alert 11.15.19
Independent Pharmacy Alliance, est. 1988, is a trade group and retail pharmacy buying cooperative representing over 3,100 independent pharmacies in New Jersey, New York, Connecticut and Pennsylvania. IPA represents its members for the purpose of combined purchasing to lower a pharmacy’s “cost of goods and services” as well as to provide them with comprehensive legislative advocacy, third party resolution support and free continuing education.