August 2020 - We have received encouraging news that some PSAOs sent notices to their membership stating that pharmacies may have been incorrectly reimbursed due to the effective date of the new law. Certain PSAOs are reviewing the new law with the PBMs. Please keep us informed of any communications you receive from your PSAOs. This will assist us in ensuring that the law is enforced by the New Jersey Department of Banking and Insurance.
* Independent Pharmacies must consider contacting their PSAOs to tell them about the new PBM law.
Please use the chart below to document the responses you received and forward them to IPA. The provisions of the law (P.L.2019, c.274 – Effective Date March 18, 2020) include:
1. Prohibits Retroactive Fees: The law specifically prohibits retroactive fees in commercial plans (excludes self-funded plans) and requires that all fees be charged at the point-of-sale. When a pharmacy adjudicates a claim at the point-of-sale, the reimbursement amount provided to the pharmacy by the PBM shall constitute a final reimbursement amount.
2. Strengthens the State MAC Law to Include Brands: Brand effective rate, generic effective rate, professional fees, any successive pricing formulas and any other pricing methodology utilized by the PBM in commercial plans are included in the MAC law.
3. Strengthens Appeals Process: If the appeal is denied, the PBM must identify the NDC of a drug product that is available for purchase by the specific contracted pharmacy appealing the claim in this State from wholesalers at a price which is available to the specific contracted pharmacy appealing the claim, and which is equal to or less than the maximum allowable cost, brand effective rate, generic effective rate or other pricing for the appealed drug as determined by the PBM.
4. All contracts must provide the sources where the pharmacies can purchase the product at the contracted rate. Pharmacies must file appeals 14 calendar days following the initial claim and the appeal shall resolved by the PBM within 14 calendar days of receipt of the appeal.
5. Mailing of Prescriptions: A pharmacy licensed in the State of New Jersey shall be permitted to make product deliveries and mail prescriptions to patients in commercial plans without contractual restrictions by a PBM.
Please Report the Responses You Receive and Note the Following
Return to IPA at Fax 609-395-1007 / email info@ipagroup.org