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Bill

A 1869

Establishes a hyperbaric oxygen therapy pilot program

2025 Regular Session Introduced by Joe Angelino and 22 co-sponsors

When a drug is denied coverage, carriers must provide the pharmacist at denial a POS-ready list of covered, interchangeable, therapeutically equivalent alternative drugs.

REFERRED TO HEALTH
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Bill Summary · A 1869

Summary of New Jersey Bill A-1869

Note: The bill’s introduced text describes a prescription drug coverage provision, not the hyperbaric oxygen therapy pilot referenced in the title. The summary below follows the actual introduced content provided.

Overview

  • Bill: A-1869
  • Title (as introduced): Establishes a hyperbaric oxygen therapy pilot program (note: the introduced text provided discusses prescription drug coverage, not hyperbaric oxygen therapy)
  • Status: Referred to HEALTH (following earlier referral to Assembly Financial Institutions and Insurance)
  • Introduced: January 9, 2024
  • Primary sponsor: Amy Paulin (with a large list of cosponsors)
  • Related bills: A-10033 (prior-session), S-1715 (companion)

Purpose and Intent

The introduced text supplements the Health Care Quality Act to improve how health benefits carriers handle denied drug coverage. Specifically, when a carrier denies coverage for a drug prescribed by a health care professional, the bill would require the carrier to provide the pharmacist with a list of alternative drugs that:
- Are covered by the health benefits plan
- Are interchangeable with the denied drug
- Are therapeutically equivalent to the denied drug

The goal is to streamline access to covered, therapeutically equivalent alternatives at the point of sale.

Key Provisions

  • At the point of denial, carriers must provide to the pharmacist:

    • A list of all alternative drugs that are covered by the plan
    • Those alternatives must be interchangeable with and therapeutically equivalent to the denied drug
    • The list must be provided to the pharmacy point of sale (POS) system at the time the denial notice is given

  • Definitions (as provided in the introduced text):

    • “Health care professional” means an individual licensed to practice a health care profession under Title 45 of the Revised Statutes.
    • “Carrier” includes entities such as sickness and accident insurers, HMOs, hospital/service corporations, MEPs, State/School benefits administrators, Medicaid-related contractors, and other entities offering health benefits plans.
    • “Pharmacist” means an individual licensed to practice pharmacy in New Jersey.

  • Effective date: The act would take effect on the 90th day after enactment.

  • Statutory alignment: The measure would supplement the Health Care Quality Act.

Affected Parties

  • Pharmacists: Would receive the POS-ready list of interchangeable, covered alternatives at the time of denial.
  • Health benefits carriers: Must implement and provide the alternative-drug lists at denial for covered prescriptions.
  • Health care professionals: Their prescribed drugs trigger the process when coverage is denied.
  • Patients/health plan enrollees: Potentially faster access to an approved alternative when a drug is denied.

Legislative History and Process

  • 2024-01-09: Introduced in the Assembly; referred to Assembly Financial Institutions and Insurance Committee
  • 2025-01-14: Referred to HEALTH (listed twice in the record)
  • Ongoing status: Referred; no final passage information available in the provided material

Potential Impacts and Considerations

  • Positive: Reduces delays in obtaining therapeutically equivalent, covered alternatives when a drug isn’t initially covered; could streamline the at-POS workflow and reduce administrative back-and-forth between providers, patients, and insurers.
  • Operational requirements: Carriers would need to maintain up-to-date formularies and ensure integration with pharmacy POS systems to deliver real-time alternative options at denial.
  • Cost and access: May influence formulary design and patient out-of-pocket costs depending on the cost difference between the denied drug and listed alternatives.
  • Clarity: The bill’s title mentions hyperbaric oxygen therapy, but the enacted text focuses on prescription drug coverage; readers should note this discrepancy when assessing intent and scope.

If you’d like, I can also draft a side-by-side comparison highlighting how the bill’s provisions would operate in typical denial scenarios (e.g., met vs. non-met alternatives, POS workflow).

Compiled from official sources — confirm details with the bill’s official record.

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