NEW JERSEY SUMMARY OF EXISTING LAW

As of March 18, 2020, after the date of receipt of a clean claim for payment made by a pharmacy, a PBM is prohibited from retroactively reducing payment on the claim, either directly or indirectly, through aggregated effective rate, direct or indirect remuneration, quality assurance program, or otherwise, except if the claim is found not to be a clean claim during the course of a routine audit performed pursuant to an agreement between the PBM and the pharmacy. When a pharmacy adjudicates a claim at the point of sale, the reimbursement amount provided to the pharmacy by the PBM must constitute a final reimbursement amount. Nothing in this section shall be construed to prohibit any retroactive increase in payment to a pharmacy pursuant to a contract between the PBM and PSAO, or a pharmacy.

Link to Existing Law: NJ ST 17B:27F–7

PRACTICAL NOTE

Prohibits a PBM from retroactively reducing payment on a properly filed claim for payment by a pharmacy thus it prohibits retrospective DIR fees. However, it must be noted that these requirements are limited to insurance plans regulated by the State, and may exclude Medicare Part D, TRICARE, and possibly ERISA-regulated plans.