Relates to military service credit

2025 Regular Session Introduced by Ken Blankenbush and 7 co-sponsors

Sets a floor for Medicaid drug reimbursement at NADAC plus $10.92, expands pharmacy choice in managed care, and requires an audit of money flows from MCOs to PBMs to pharmacies.

HELD FOR CONSIDERATION IN GOVERNMENTAL EMPLOYEES

Summary — A5531 (Equitable Drug Pricing and Patient Access Act)

Status and procedural history
- Introduced: April 10, 2025 (Assembly).
- Committee: Referred to Governmental Employees; listed as HELD FOR CONSIDERATION in Governmental Employees (May 19, 2025).
- Companion: S3538. Prior-session related bill: A9379.
- Sponsors: Assemblywomen Yvonne Lopez, Margie Donlon, Luanne Peterpaul (primaries) and multiple cosponsors.

Purpose
- To increase transparency and set minimum payment standards for Medicaid prescription drug reimbursement, expand pharmacy choice for Medicaid managed care enrollees, and require an audit of pharmacy pricing flows (managed care orgs → pharmacy benefit managers → pharmacies).

Key provisions
1. Reimbursement floor
- For Medicaid prescription drug services (fee-for-service and managed care), reimbursement to pharmacies must be no less than the national average drug acquisition cost (NADAC) for the drug plus a professional dispensing fee of $10.92, “to the extent” consistent with federal law and regulation.

Pharmacy choice as a required managed-care benefit

Medicaid managed care contracts must allow all New Jersey pharmacies to dispense covered medications regardless of drug cost or carrier-developed criteria.
Pharmacies must accept plan terms but cannot be required to dispense at a price below their acquisition cost.
Plan terms must permit fair participation by all pharmacies.
Out‑of‑network pharmacies must be reimbursed at the same rate applicable to in‑network pharmacies for the same service.

Provider participation rules

MCOs must permit enrollees to choose any qualified contracting pharmacy.
No pharmacy may be denied contracting rights if it accepts contract terms.

Audit and oversight

State Auditor must audit pharmacy pricing practices and trace the flow of funds from managed care organizations to PBMs to pharmacies to determine the savings the State should realize from the bill’s provisions.

Implementation mechanics

Commissioner of Human Services must seek any necessary State Plan Amendments or federal waivers to secure federal financial participation.
Commissioner may adopt implementing regulations.
Effective on the first day of the seventh month after enactment; applies to managed-care contracts executed on or after that date.

Who is affected
- Medicaid beneficiaries (greater pharmacy choice and potentially more consistent access).
- Retail and independent pharmacies (payment floor, contracting protections).
- Medicaid managed care organizations (contracting and reimbursement requirements).
- Pharmacy benefit managers (subject of audit/flow‑of‑funds review).
- State agencies (DHS implementation, State Auditor review).

Potential impacts and considerations
- May increase pharmacy reimbursement and beneficiary access to pharmacies; could raise Medicaid prescription drug spending unless offset by other savings.
- Implementation requires federal coordination (state plan amendments/waivers) because of managed-care and Medicaid funding rules.
- Audit requirement aims to identify inefficiencies and savings but the bill does not specify how identified savings would be realized or redistributed.