Lampitt, Vainieri Huttle, Benson Bill to Ensure Chronically Ill Patients Continue to Receive Coverage for Critical Medications Advances in Assembly

(TRENTON) - Legislation sponsored by Assembly Democrats Pamela Lampitt, Valerie Vainieri Huttle, and Daniel Benson to require health insurance carriers to provide continued coverage of prescription drugs for covered persons diagnosed with a complex or chronic medical condition or a rare disease was approved by an Assembly panel on Thursday.

The bill (A-4205) defines "complex or chronic medical condition" as a physical, behavioral, or developmental condition that does not have a known cure or that can be severely debilitating or fatal if left untreated or undertreated. "Rare disease" is defined under the bill as any disease or condition that affects less than 200,000 persons in the United States.

"Many patients who are suffering from a chronic medical condition find themselves in lurch when health insurance carriers stop carrying the medicine they need to manage their disease or illness," said Lampitt (D-Camden, Burlington). "This legislation will help ensure patients with a chronic medical condition will receive the medicine they need to live their best lives."

"Many times a health insurance carrier will stop providing a certain medication but still cover a generic, sometimes less effective form," said Vainieri Huttle (D-Bergen). "Patients who endure daily symptoms of a chronic medical illness should have a choice whether to continue the medication that works for them and not have to settle for a generic brand that may not work."

The bill also would require hospital, medical and health service corporations, commercial insurers, health maintenance organizations, health benefits plans issued pursuant to the New Jersey Individual Health Coverage and Small Employer Health Benefits Programs, prepaid prescription service organizations, and plans provided by the State Health Benefits Commission and the School Employees' Health Benefits Commission to provide continued coverage of a prescription drug prescribed for a complex or chronic medical condition or rare disease when the drug: 

  1. was previously covered by the carrier; and 
  2. the prescribing provider continues to prescribe the drug for the medical condition or disease, provided the drug is appropriately prescribed, and the United States Food and Drug Administration (USFDA) has not indicated usage should cease. 

"When a patient finds a medication that works for them, they should have the option to continue that medication without interruption," said Benson (D-Mercer, Middlesex). "The medicine should continue to be covered by health insurance carriers for as long as the patient needs it."

The bill would further provide that a carrier shall not set forth limitations on maximum coverage of prescription drug benefits; subject the covered person to increased out-of-pocket costs; or move a drug for a covered person to a more restrictive tier, if the carrier uses a formulary with tiers.

The bill would take effect on the 90th day next following enactment.

The Assembly Financial Institutions and Insurance committee approved the bill; it will now go to the Assembly Speaker for further consideration.