Bill Text: NJ A3080 | 2012-2013 | Regular Session | Introduced
Bill Title: Requires health benefits coverage for refills of prescription eye drops under certain conditions.
Spectrum: Strong Partisan Bill (Democrat 10-1)
Status: (Passed) 2013-05-06 - Approved P.L.2013, c.50. [A3080 Detail]
Download: New_Jersey-2012-A3080-Introduced.html
Sponsored by:
Assemblyman GARY S. SCHAER
District 36 (Bergen and Passaic)
SYNOPSIS
Requires health benefits coverage for refills of prescription eye drops under certain conditions.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning health benefits coverage for prescription eye drops and supplementing various parts of the statutory law.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. a. A hospital service corporation which provides hospital or medical expense benefits that include coverage for prescription eye drops under a contract delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred for refills of prescription eye drops in accordance with the Guidance for Early Refill Edits of Topical Ophthalmic Products provided to Medicare Part D plan sponsors by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services, provided that:
(1) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; and
(2) the refill requested by the subscriber or covered person does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner.
b. The provisions of this section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium.
2. a. A medical service corporation which provides hospital or medical expense benefits that include coverage for prescription eye drops under a contract delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred for refills of prescription eye drops in accordance with the Guidance for Early Refill Edits of Topical Ophthalmic Products provided to Medicare Part D plan sponsors by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services, provided that:
(1) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; and
(2) the refill requested by the subscriber or covered person does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner.
b. The provisions of this section shall apply to all medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.
3. a. A health service corporation which provides hospital or medical expense benefits that include coverage for prescription eye drops under a contract delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred for refills of prescription eye drops in accordance with the Guidance for Early Refill Edits of Topical Ophthalmic Products provided to Medicare Part D plan sponsors by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services, provided that:
(1) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; and
(2) the refill requested by the subscriber or covered person does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner.
b. The provisions of this section shall apply to all health service corporation contracts in which the health service corporation has reserved the right to change the premium.
4. a. An individual health insurer which provides hospital or medical expense benefits that include coverage for prescription eye drops under a policy delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred for refills of prescription eye drops in accordance with the Guidance for Early Refill Edits of Topical Ophthalmic Products provided to Medicare Part D plan sponsors by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services, provided that:
(1) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; and
(2) the refill requested by the insured or covered person does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner.
b. The provisions of this section shall apply to those policies in which the insurer has reserved the right to change the premium.
5. a. A group health insurer which provides hospital or medical expense benefits that include coverage for prescription eye drops, under a policy delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred for refills of prescription eye drops in accordance with the Guidance for Early Refill Edits of Topical Ophthalmic Products provided to Medicare Part D plan sponsors by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services, provided that:
(1) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; and
(2) the refill requested by the insured or covered person does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner.
b. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.
6. a. An individual health benefits plan which provides hospital or medical expense benefits that include coverage for prescription eye drops under a contract delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred for refills of prescription eye drops in accordance with the Guidance for Early Refill Edits of Topical Ophthalmic Products provided to Medicare Part D plan sponsors by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services, provided that:
(1) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; and
(2) the refill requested by the covered person does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner.
b. The provisions of this section shall apply to all individual health benefits plans in which the carrier has reserved the right to change the premium.
7. a. A small employer health benefits plan which provides hospital or medical expense benefits that include coverage for prescription eye drops under a contract delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred for refills of prescription eye drops in accordance with the Guidance for Early Refill Edits of Topical Ophthalmic Products provided to Medicare Part D plan sponsors by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services, provided that:
(1) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; and
(2) the refill requested by the subscriber or covered person does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner.
b. The provisions of this section shall apply to all small employer health benefits plans in which the carrier has reserved the right to change the premium.
8. a. A health maintenance organization contract which provides hospital or medical expense benefits that include coverage for prescription eye drops, issued or continued in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide coverage for expenses incurred for refills of prescription eye drops in accordance with the Guidance for Early Refill Edits of Topical Ophthalmic Products provided to Medicare Part D plan sponsors by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services, provided that:
(1) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; and
(2) the refill requested by the enrollee or covered person does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner.
b. The provisions of this section shall apply to those contracts for health care services by health maintenance organizations under which the health maintenance organization has reserved the right to change the schedule of charges.
9. The State Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits that include coverage for prescription eye drops, shall provide coverage for expenses incurred for refills of prescription eye drops in accordance with the Guidance for Early Refill Edits of Topical Ophthalmic Products provided to Medicare Part D plan sponsors by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services, provided that:
(1) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; and
(2) the refill requested by the covered person does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner.
10. The School Employees' Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits that include coverage for prescription eye drops, shall provide coverage for expenses incurred for refills of prescription eye drops in accordance with the Guidance for Early Refill Edits of Topical Ophthalmic Products provided to Medicare Part D plan sponsors by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services, provided that:
(1) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; and
(2) the refill requested by the covered person does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner.
11. This act shall take effect on the 90th day after enactment.
STATEMENT
This bill requires, in certain circumstances, health insurers (health, hospital and medical service corporations, commercial individual and group health insurers; health maintenance organizations, health benefits plans issued pursuant to the New Jersey Individual Health Coverage and Small Employer Health Benefits Programs, the State Health Benefits Program, and the School Employees' Health Benefits Program) that provide coverage for prescription eye drops, to provide health benefits coverage for expenses incurred for a refill of prescription eye drops in accordance with Guidance for Early Refill Edits on Topical Ophthalmic Products provided to Medicare Part D plan sponsors by the Centers for Medicare and Medicaid Services.
The requirement to provide this coverage is conditioned on two factors: (1) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; and (2) the refill requested does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner.
The Centers for Medicaid and Medicare Services issued guidance on topical ophthalmics to prevent the unintended interruption of drug therapy in situations in which patients legitimately need earlier refills of prescription eye drops. While the guidance acknowledges that health insurers monitor appropriate refill periods as part of utilization management, the guidance also recognizes that the self-administration of prescription eye drops may involve some reasonable amount of waste and that earlier refills may be appropriate in some circumstances.
