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Bill

A 4694

Requires prescription drug coverage for serious mental illness without prior authorization or utilization management, including step therapy.

2026-2027 Regular Session Introduced by Aura Dunn and 7 co-sponsors

Expands coverage for serious mental illness meds without prior authorization or step therapy, including for Medicaid/NJ FamilyCare, to improve access.

Introduced, Referred to Assembly Health Committee
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Bill Summary · A 4694

Summary of Bill A-4694 (New Jersey, 222nd Session)

Purpose and Intent

Bill A-4694 aims to ensure that prescription drugs for serious mental illness (SMI) are covered by health insurance plans, Medicaid, and NJ FamilyCare without prior authorization or other utilization management requirements. This includes prohibiting step therapy and similar non-quantitative treatment limitations (NQTLs) for SMI medications when prescribed by qualified clinicians. The bill also enhances state enforcement and reporting related to mental health parity.

Key Provisions

1) Expanded prohibition on prior authorization for SMI drugs

  • Applies to:
    • Private health carriers (insurance companies, HMO, PPO, etc.) and plans administered for state programs under New Jersey law.
    • Medicaid and NJ FamilyCare enrollees.
  • Coverage is required for prescription drugs prescribed for serious mental illness if the prescriber is:
    • A psychiatrist; or
    • An obstetrician/gynecologist (OB/GYN) during the postpartum period.
  • Important limitations:
    • The no-prior-authorization requirement also covers other utilization management tools, including step therapy protocols.
    • Applies only to individuals aged 18 and older.

2) Continuation of therapy without additional approvals

  • If a patient has been stable for at least six months on a drug prescribed by a psychiatrist or OB/GYN, another prescriber may continue prescribing the same drug without prior authorization or utilization management requirements.

3) Definition framework

  • Clarifies what constitutes “serious mental illness” for the purposes of coverage, listing:
    • Schizophrenia and schizoaffective/bipolar disorders (including related mood states)
    • Major depressive disorders (including peripartum onset)
    • Post-traumatic stress disorder (PTSD)
  • Establishes definitions for “carrier,” “utilization management,” and “NQTLs” consistent with federal parity standards.

4) Medicaid/NJ FamilyCare and managed care requirements

  • The division of Medical Assistance and Health Services must ensure that managed care organizations contracted with the division comply with these protections for SMI medications.

5) Parity oversight and reporting (Department of Banking and Insurance)

  • Annual reporting (due by May 1 each year) detailing:
    • Processes for developing medical necessity criteria for mental health and SUD benefits versus medical/surgical benefits.
    • NQTL identification and analysis across mental health, SMI, SUD, and medical/surgical benefits.
    • Comparative analyses demonstrating parity in application of criteria and NQTLs.
    • Market conduct examinations, results, and corrective actions.
    • Public-facing, non-technical summaries, and educational efforts related to parity protections.
  • Creation of a public, redacted consumer complaint log related to parity violations.
  • The department may adopt rules to implement parity provisions.

Who Is Affected

  • Individuals with private health insurance plans, including state-related programs, who are treated for serious mental illness and are 18+.
  • Medicaid and NJ FamilyCare enrollees seeking SMI medications.
  • Prescribers (psychiatrists and OB/GYNs during postpartum periods) who prescribe SMI medications for covered patients.
  • Managed care organizations contracted with the state for Medicaid/NJ FamilyCare.

Effective Date

  • Enactment takes effect on the 180th day after enactment and applies to policies issued or renewed on or after that date.

Potential Impact

  • Improves access to essential SMI medications by reducing administrative barriers.
  • Aligns state practices with federal parity requirements, enhancing consistency and accountability.
  • Creates a framework for ongoing monitoring, transparency, and enforcement of mental health parity standards.

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

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