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A 1825

Waives a registration fee for basic life support first response agencies

2025 Regular Session Introduced by Joe Angelino

Regulates state step-therapy rules for NJ plans, mandates evidence-based guidelines and an accessible exceptions process to ensure timely drug coverage when clinically warranted.

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Bill Summary · A 1825

Summary — A-1825 (Assembly Committee Substitute / AAP ACS)

An Act concerning step therapy protocols; enacted as P.L.2025, c.50 (approved May 8, 2025)

Main purpose

To regulate the use and administration of prescription drug "step therapy" protocols for State-covered plans (State Health Benefits Program, School Employees’ Health Benefits Program, and NJ FamilyCare/Medicaid), and to create a transparent, timely exceptions process that preserves clinicians’ ability to obtain coverage for the drug they determine is medically appropriate.

Key provisions and changes

  • Scope: Applies to the State Health Benefits Program, School Employees’ Health Benefits Program, NJ FamilyCare (Medicaid/CHIP), vendors administering the State plans, managed care organizations, and utilization review organizations. (Commercial market plans are exempt under certain earlier versions.)
  • Clinical review criteria:
    • Step therapy protocols must be based on clinical practice guidelines developed or endorsed by a multidisciplinary expert panel that: relies on objective data, manages conflicts of interest, is based on high‑quality evidence, is developed via a transparent process (that rates evidence and considers patient subgroups/preferences), and is reviewed regularly (annually or quarterly if new information emerges).
    • In absence of appropriate guidelines, peer‑reviewed literature may be used.
    • Entities must consider needs of atypical patient populations when creating protocols.
  • Exceptions process:
    • Carriers/managed care organizations must provide a clear, readily accessible process (website explanation acceptable; may use existing medical exceptions processes) for prescribers or patients to request a step therapy exception (i.e., immediate coverage of the prescriber’s selected drug).
    • Grounds for granting an exception (as specified in the enacted language) include that the required drug is contraindicated or likely to cause harm; is expected to be ineffective or less effective given patient characteristics; or all relevant formulary drugs have been ineffective or caused adverse reactions for the patient.
    • If requested, prescribers must provide documentation supporting the exception determination.
    • Authorization upon grant: coverage must be authorized for at least 180 days (or the full duration if less than 180 days), provided the drug is covered by the plan.
  • Timelines and appeals:
    • Carriers/organizations must decide exception requests and appeals within timeframes appropriate to medical exigencies but not later than 24 hours for urgent requests and 72 hours for non‑urgent requests after obtaining all necessary information. Some versions provide that failure to respond within the required time results in the exception being deemed granted.
    • Exceptions decisions are appealable by covered persons.
  • Transparency and reporting:
    • Clinical review criteria must be made available on request and posted on internet sites (provider portals). Carriers/organizations must make certain information about exception requests, approvals, denials, and appeals available as determined by the appropriate Commissioner and/or on their website.

Who is affected

  • Primary: enrollees in New Jersey State Health Benefits Program, School Employees’ Health Benefits Program, and NJ FamilyCare (Medicaid/CHIP) and their treating providers.
  • Administrative entities: vendors, managed care organizations, utilization review organizations.
  • Local governments that purchase coverage through the State plans may experience fiscal impacts; commercial market plans and some non‑State plans may be exempt depending on version.

Fiscal and programmatic impact

  • Office of Legislative Services (OLS) estimate: indeterminate increases in annual State and local expenditures (primarily due to potentially greater use of higher‑cost drugs when exceptions are granted). The bill could increase NJ FamilyCare expenditures and thereby raise State revenue from federal Medicaid matching funds (historically about $0.64 federal for each $1.00 State Medicaid spend). OLS noted potential offsetting savings if improved treatment outcomes reduce downstream costs. The Department of Human Services may incur administrative costs (e.g., plan amendments/waivers to secure federal matching).

Procedural / timeline notes

  • Introduced: Jan 9, 2024.
  • Committee and floor actions: reported and amended in various committees (Health; Financial Institutions & Insurance; Appropriations).
  • Passed both houses: Assembly (75–2–0) and Senate (39–0) on March 24, 2025.
  • Enacted: Approved as P.L.2025, c.50 (May 8, 2025).
  • Sponsors / related legislation: Primary sponsor Joe Angelino; companion/related Senate bills include S3533, S731, and prior‑session measures.

This summary highlights the law’s intent to balance cost‑control uses of step therapy with safeguards for patient safety, clinician judgment, timely access to needed medications, and transparency in how step therapy rules are developed and applied.

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

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