reglab/statecodes huggingface dataset:
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27D-4 - Membership; terms; vacancies.

17B:27D-4 Membership; terms; vacancies.
4. The commission shall consist of 17 voting members as follows: the Commissioners of Health, Human Services and Banking and Insurance or their designees, who shall serve ex officio; three public members appointed by the President of the Senate, who shall include a representative of a commercial health insurance company, a physician licensed in this State who is a member of the Medical Society of New Jersey, and a representative of the New Jersey Business and Industry Association, no more than two of whom shall be from the same political party; three public members appointed by the Speaker of the General Assembly, who shall include a representative of a health service corporation, a physician licensed in this State, and a representative of organized labor, no more than two of whom shall be from the same political party; and eight public members appointed by the Governor, who shall include a medical educator from Rutgers, The State University whose major field of expertise is the study and evaluation of the cost of health care and health insurance, a representative of the New Jersey Association of Health Plans, a representative of the New Jersey Hospital Association, a representative of the New Jersey State Nurses Association, a representative of the New Jersey Dental Association, a representative of a consumer advocacy organization and two representatives of the general public who are knowledgeable about health benefits plans.
The President of the Senate may appoint two members of the Senate, no more than one of whom shall be from the same political party, to serve as nonvoting members of the commission. The Speaker of the General Assembly may appoint two members of the General Assembly, no more than one of whom shall be from the same political party, to serve as nonvoting members of the commission. The legislative members shall serve during their legislative term of office.
Of the voting members first appointed, four shall serve for a term of two years, four for a term of three years, and three for a term of four years.
Voting members appointed thereafter shall serve four-year terms, and any vacancy shall be filled by appointment for the unexpired term only. A member is eligible for reappointment. Vacancies in the membership of the commission shall be filled in the same manner as the original appointments were made.
L.2003, c.193, s.4; amended 2012, c.17, s.61; 2012, c.45, s.66.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27D-5 - Election of chairman, vice chairman, appointment of secretary; meetings.

17B:27D-5 Election of chairman, vice chairman, appointment of secretary; meetings.
5. a. The commission shall organize and hold its first meeting within 90 days after the appointment of its members and shall elect a chairman and a vice chairman from among its members. The commission may appoint a secretary, who need not be a member of the commission.
b. The members of the commission shall serve without compensation but may be allowed their actual and necessary expenses incurred in the performance of their duties within the limits of funds appropriated or otherwise made available to the commission for this purpose.
c. The Department of Banking and Insurance, in consultation with the Department of Health, shall assist the commission in the performance of its duties.
d. The commission shall be entitled to call upon the services of any State, county or municipal department, board, commission or agency as it may require and as may be available to it for these purposes, and to incur such traveling and other miscellaneous expenses as it may deem necessary for the proper execution of its duties and as may be within the limit of funds appropriated or otherwise made available to it for these purposes.
e. The commission shall meet regularly, and at a minimum of four times per year. Special meetings may be called by the chairman of the commission.
L.2003, c.193, s.5; amended 2012, c.17, s.62.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27D-8 - Development of system of data collection; review, comment.

17B:27D-8 Development of system of data collection; review, comment.
8. In the course of studying and evaluating proposed mandated health benefits, the commission shall:
a. develop criteria for a system and program of data collection, for use by the Departments of Health and Banking and Insurance, to assess the impact of mandated health benefits, including the cost to employers and carriers, impact of treatment, cost savings in the health care system, number of providers, and other data as may be appropriate; and
b. review and comment to any State department, board, bureau, commission, or agency, with respect to any order or regulations proposed or implemented thereby that affect mandated health benefits.
L.2003, c.193, s.8; amended 2012, c.17, s.65.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27D-9 - Report to Governor, Legislature

17B:27D-9. Report to Governor, Legislature
9. The commission shall report to the Governor and Legislature three years from the effective date of this act on its activities. The report shall include a summary of the bills reviewed by the commission and the commission's findings, and any recommendations the commission may have regarding the review process required pursuant to this act.
L.2003,c.193,s.9.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27D-10 - Report by Mandated Health Benefits Advisory Commission.

17B:27D-10 Report by Mandated Health Benefits Advisory Commission.
13. a. Notwithstanding the provisions of any other law to the contrary, the Mandated Health Benefits Advisory Commission established pursuant to section 3 of P.L.2003, c.193 (C.17B:27D-3), shall prepare a report regarding the implementation and administration of P.L.2013, c.196 (C.26:2-184.3 et al.) at least once in each five-year period following the effective date of P.L.2013, c.196 (C.26:2-184.3 et al.).
b. The report shall provide a summary of the social and financial impact, as well as the medical efficacy, of the requirements imposed by P.L.2013, c.196 (C.26:2-184.3 et al.), and shall provide a summary of any recommendations the commission may have to improve the effectiveness of P.L.2013, c.196 (C.26:2-184.3 et al.).
c. The commission shall transmit a copy of a report prepared in accordance with this section to the Governor, and to the Legislature, in accordance with section 2 of P.L.1991, c.164 (C.52:14-19.1), within five days of the date the report is prepared.
L.2013, c.196, s.13.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27D-11 - Work group regarding risk factors for breast cancer, breast imaging options.

17B:27D-11 Work group regarding risk factors for breast cancer, breast imaging options.
14. a. The Department of Health, in conjunction with the Medical Society of New Jersey, shall convene a work group to review and report on strategies to improve the dialogue between patients and health care professionals regarding risk factors for breast cancer and breast imaging options. The work group shall review breast imaging standards, the federal Mammography Quality Standards Act and breast imaging results protocols, and shall recommend strategies to improve the dialogue between patients and health care professionals regarding breast density and breast imaging options.
b. The department shall invite to participate in the work group representatives of patient advocacy groups and health care professionals' organizations. The work group shall organize as soon as practicable following the appointment of its members. The members of the work group shall serve without compensation, but shall be reimbursed for necessary expenses incurred in the performance of their duties and within the limits of funds available to the work group.
c. The work group shall be entitled to call to its assistance and avail itself of the services of the employees of any State, county, or municipal department, board, bureau, commission, or agency as the work group may require and as may be available to the work group for its purposes.
d. The work group shall report its findings and recommendations to the Governor, and to the Legislature pursuant to section 2 of P.L.1991, c.164 (C.52:14-19.1), along with any legislative bills that it desires to recommend for adoption by the Legislature, on an annual basis. The work group shall submit its first report no later than 12 months after the initial meeting of the work group.
L.2013, c.196, s.14.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27E-1 - Purpose of act on long-term care insurance

17B:27E-1. Purpose of act on long-term care insurance
1. The purpose of this act is to promote the public interest, to promote the availability of long-term care insurance policies, to protect applicants for long-term care insurance from unfair or deceptive sales or enrollment practices, to establish standards for long-term care insurance, to facilitate public understanding and comparison of long-term care insurance policies, and to facilitate flexibility and innovation in the development of long-term care insurance coverage.
L.2003,c.207,s.1.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27E-2 - Application of act

17B:27E-2. Application of act
2. The requirements of this act shall apply to policies delivered or issued for delivery in this State on or after the effective date of this act intended for use as long-term care insurance. This act is not intended to supersede the obligations of entities subject to this act to comply with the substance of other applicable insurance laws insofar as they do not conflict with this act, except that laws and regulations designed and intended to apply to Medicare supplement insurance policies shall not be applied to long-term care insurance.
L.2003,c.207,s.2.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27E-5 - Compliance required

17B:27E-5. Compliance required
5. a. Any policy, certificate or rider advertised, marketed or offered as long-term care insurance shall comply with the provisions of this act.
b. No group long-term care insurance coverage shall be offered to a resident of this State under a group policy issued in another state to a group described in paragraph (2) of the definition of "group long-term care insurance" in section 4 of this act, unless this State, or another state having statutory and regulatory long-term care insurance requirements substantially similar to those adopted in this State, has made a determination that those requirements have been met.
L.2003,c.207,s.5.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27E-7 - Grounds for rescinding policy, denying a claim

17B:27E-7. Grounds for rescinding policy, denying a claim
7. a. For a policy or certificate that has been in force for less than six months, an insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation that is material to the acceptance for coverage.
b. For a policy or certificate that has been in force for at least six months but less than two years, an insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation that is both material to the acceptance for coverage and which pertains to the condition for which benefits are sought.
c. After a policy or certificate has been in force for two years, it is not contestable upon the grounds of misrepresentation alone; such a policy or certificate may be contested only upon a showing that the insured knowingly and intentionally misrepresented relevant facts relating to the insured's health.
d. If an insurer has paid benefits under the long-term care insurance policy or certificate, the benefit payments shall not be recovered by the insurer if the policy or certificate is rescinded.
e. In the event of the death of the insured, this section shall not apply to the remaining death benefit of a life insurance policy that accelerates benefits for long-term care. In this situation, the remaining death benefits under these policies shall be governed by N.J.S.17B:25-4 or 17B:27-12, as appropriate. In all other situations, this section shall apply to life insurance policies that accelerate benefits for long-term care.
L.2003,c.207,s.7.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27E-8 - Conditions for delivery, issuance of policy

17B:27E-8. Conditions for delivery, issuance of policy
8. a. Except as provided in subsection b. of this section, a long-term care insurance policy shall not be delivered or issued for delivery in this State unless the policyholder or certificate holder has been offered the option of purchasing a policy or certificate including a nonforfeiture benefit. The offer of a nonforfeiture benefit may be in the form of a rider that is attached to the policy. If the policyholder or certificate holder declines the nonforfeiture benefit, the insurer shall provide a contingent benefit upon lapse that shall be available for a specified period of time following a substantial increase in premium rates.
b. When a group long-term care insurance policy is issued, the offer required in subsection a. of this section shall be made to the group policyholder.
L.2003,c.207,s.8.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27E-9 - Regulations

17B:27E-9. Regulations
9. The commissioner shall promulgate regulations, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), necessary to effectuate the purposes of this act including, but not limited to, regulations dealing with disclosure requirements, eligibility, renewability, non-duplication of coverage, dependent coverage, preexisting conditions, termination of coverage, continuation or conversion, loss ratio, and other information that the commissioner feels necessary.
L.2003,c.207,s.9.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27E-11 - Insurer to file rates, rating schedule, supporting documentation

17B:27E-11. Insurer to file rates, rating schedule, supporting documentation
11. An insurer providing long-term care insurance issued on an individual basis in this State shall file, for the commissioner's approval, its rates, rating schedule and supporting documentation demonstrating that it is in compliance with the applicable loss ratio standards of this State. All filings of rates and rating schedules shall demonstrate that the benefits are reasonable in relation to the premium charged and that the rates are not excessive, inadequate or unfairly discriminatory.
L.2003,c.207,s.11.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27E-12 - Additional penalties

17B:27E-12. Additional penalties
12. In addition to any other penalties provided by the laws of this State, any insurer and any insurance producer found to have violated any requirement of this State relating to the regulation of long-term care insurance or the marketing of that insurance shall be subject to a fine of up to three times the amount of any commissions paid for each policy or certificate involved in the violation, or $10,000, whichever is greater.
L.2003,c.207,s.12.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27F-2 - Duties, pharmacy benefits manager, contracts.

17B:27F-2 Duties, pharmacy benefits manager, contracts.
2. Upon execution or renewal of each contract, or at such a time when there is any material change in the term of the contract, a pharmacy benefits manager shall, with respect to contracts between a pharmacy benefits manager and a pharmacy services administrative organization, or between a pharmacy benefits manager and a contracted pharmacy:
a. (1) include in the contract the sources utilized to determine multiple source generic drug pricing, brand drug pricing, and the wholesaler in the State of New Jersey where pharmacies may acquire the product, including, but not limited to, the brand effective rate, generic effective rate, dispensing fee effective rate, maximum allowable cost or any other pricing formula for pharmacy reimbursement;
(2) update that pricing information every seven calendar days; and
(3) establish a reasonable process by which contracted pharmacies have a method to access relevant maximum allowable cost pricing lists, brand effective rate, generic effective rate, and dispensing fee effective rate, or any other pricing formulas for pharmacy reimbursement.
b. Additionally, a pharmacy benefits manager shall:
(1) maintain a procedure to eliminate drugs from the list of drugs subject to multiple source generic drug pricing and brand drug pricing, or modify maximum allowable cost rates, brand effective rate, generic effective rate, dispensing fee effective rate or any other applicable pricing formula in a timely fashion and make that procedure easily accessible to the pharmacy services administrative organizations or the pharmacies that they are contractually obligated with to provide that information according to the requirements of this section; and
(2) provide an internal appeal mechanism to resolve any dispute raised by a carrier or pharmacy, regardless of whether the carrier or pharmacy benefits manager has a contract to challenge maximum allowable costs for a specified drug. Any dispute regarding the determination of an internal appeal conducted pursuant to this subsection may be referred to arbitration. The Commissioner of Banking and Insurance shall contract with a nationally recognized, independent organization that specializes in arbitration to conduct the arbitration proceedings.
L.2015, c.179, s.2; amended 2019, c.274, s.3; 2023, c.107, s.4.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27F-3.1 - Carrier duties, responsibilities.

17B:27F-3.1 Carrier duties, responsibilities.
3. a. A carrier shall:
(1) monitor all activities carried out on behalf of the carrier by a pharmacy benefits manager if the carrier contracts with a pharmacy benefits manager and is related to a carrier's prescription drug benefits; and
(2) ensure that all requirements of this section are met.
b. A carrier that contracts with a pharmacy benefits manager to perform any activities related to the carrier's prescription drug benefits shall ensure that, under the contract, the pharmacy benefits manager acts as the carrier's agent in good faith and fair dealing in the performance of all of its contractual duties. All funds received by the pharmacy benefits manager in relation to providing pharmacy benefits management services shall be used or distributed only pursuant to the pharmacy benefits manager's contract with the health benefits plan or carrier or applicable law; including any administrative fee or payment to the pharmacy benefits manager expressly provided for in the contract to compensate the pharmacy benefits manager for its services. Any funds received by the pharmacy benefits manager through spread pricing shall be subject to this subsection.
c. (1) A pharmacy benefits manager interacting with a covered person shall have the same duty to a covered person as the health benefits plan or carrier for whom it is performing pharmacy benefits management services.
(2) A pharmacy benefits manager shall have a duty of good faith and fair dealing with all parties, including but not limited to covered persons and pharmacies, with whom it interacts in the performance of pharmacy benefits management services.
d. A carrier or pharmacy benefits manager shall not require a covered person to make a payment at the point of sale for a covered prescription drug in an amount greater than the lesser of:
(1) the applicable cost-sharing amount for the prescription drug; or
(2) the amount a covered person would pay for the prescription medication if the covered person purchased the prescription medication without using a health benefits plan.
e. A carrier shall provide a reasonably adequate retail pharmacy network for the provision of prescription drugs for its covered persons.
f. For the purposes of this section, "health benefits plan" shall include the State Health Benefits Plan, the School Employees' Health Benefits Plan, the State Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), or a self-insured health benefits plan governed by the provisions of the federal "Employee Retirement Income Security Act of 1974," 29 U.S.C., ss.1001 et seq.
L.2023, c.107, s.3.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27F-3.2 - Compensation remitted, pharmaceutical manufacturer, developer, labeler, carrier, pharmacy benefits manager under contract; report.

17B:27F-3.2 Compensation remitted, pharmaceutical manufacturer, developer, labeler, carrier, pharmacy benefits manager under contract; report.
6. a. Compensation remitted by or on behalf of a pharmaceutical manufacturer, developer or labeler, directly or indirectly, to a carrier or to a pharmacy benefits manager under contract with a carrier related to prescription drug benefits shall be:
(1) remitted directly to the covered person at the point of sale to reduce the out-of-pocket cost to the covered person associated with a particular prescription drug; or
(2) remitted to, and retained by, the carrier. Compensation remitted to the carrier shall be applied by the carrier in its plan design and in future plan years to offset the premium for covered persons.
b. Beginning on March 1 next following the effective date of P.L.2023, c.107 (C.17B:27F-1.1 et al.), and annually thereafter, a carrier shall file with the department a report explaining how the carrier has complied with the provisions of this section. The report shall be written in a manner and form determined by the department.
c. Nothing in this section shall preclude a carrier or pharmacy benefits manager under contract with a carrier from implementing a program designed to lower a covered person's out-of-pocket cost or decreasing a covered person's out-of-pocket cost by an amount greater than that required under subsection a. of this section.
d. As used in this section, "compensation" means any direct or indirect financial benefit, including, but not limited to, rebates, discounts, credits, fees, grants, chargebacks or other payments or benefits of any kind, that is attributed to, directly or indirectly, the utilization of a health benefits plan or enrollment in a health benefits plan, regardless of how the benefits are otherwise characterized by a pharmacy benefits manager and relevant third parties.
L.2023, c.107, s.6.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27F-3.3 - Carrier, pharmacy benefits manager under contract, pharmacy and therapeutics committee, established, formulary system management.

17B:27F-3.3 Carrier, pharmacy benefits manager under contract, pharmacy and therapeutics committee, established, formulary system management.
7. a. A carrier, or a pharmacy benefits manager under contract with a carrier, shall establish a pharmacy and therapeutics committee responsible for managing the formulary system.
b. A carrier, or a pharmacy benefits manager under contract with a carrier, shall not allow a person with a conflict of interest to be a member of its pharmacy and therapeutics committee.
A carrier, or a pharmacy benefits manager under contract with a carrier, shall require that its pharmacy and therapeutics committee meet the requirements for conflict of interest as set by the Centers for Medicare and Medicaid Services or meets the accreditation standards of the National Committee for Quality Assurance or another independent accrediting organization.
L.2023, c.107, s.7.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27F-3.4 - Carrier, use of pharmacy benefits manager, administer, manage, prescription drug benefits, claims, parameters.

17B:27F-3.4 Carrier, use of pharmacy benefits manager, administer, manage, prescription drug benefits, claims, parameters.
9. a. If a carrier uses a pharmacy benefits manager to administer or manage the prescription drug benefits of covered persons, any pharmacy benefits manager compensation, for purposes of calculating a carrier's anticipated loss ratio or any loss ratio calculated as part of any applicable medical loss ratio filing or rate filing, shall:
(1) constitute an administrative cost incurred by the carrier in connection with a health benefits plan; and
(2) not constitute a benefit provided under a health benefits plan. A carrier shall claim only the amounts paid by the pharmacy benefits manager to a pharmacy or pharmacist as an incurred claim.
b. Any rate filing submitted by a carrier with respect to a health benefits plan that provides coverage for prescription drugs or pharmacy services and that is administered or managed by a pharmacy benefits manager shall include:
(1) a memorandum prepared by a qualified actuary describing the calculation of the pharmacy benefits manager compensation; and
(2) any records and supporting information as the department reasonably determines is necessary to confirm the calculation of the pharmacy benefits manager compensation.
c. Upon request, a carrier shall provide any records to the department that relate to the calculation of the pharmacy benefits manager and pharmacy services administrative organization compensation.
d. A pharmacy benefits manager and pharmacy services administrative organization shall provide any necessary documentation requested by a carrier that relates to pharmacy benefits manager compensation in order to comply with the requirements of this section.
L.2023, c.107, s.9.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27F-4 - Process for appeals, investigation and dispute.

17B:27F-4 Process for appeals, investigation and dispute.
4. All contracts between a pharmacy benefits manager and a pharmacy services administrative organization, or its contracted pharmacies, and all contracts directly between a pharmacy benefits manager and a pharmacy shall include a process to appeal, investigate, and resolve disputes regarding brand andmultiple source generic drug pricing, including, if applicable, brand effective rate, generic effective rate, dispensing fee effective rate, and any other pricing formula for pharmacy reimbursement. The contract provision establishing the process shall include the following:
a. The right to appeal shall be limited to 14 calendar days following the initial claim;
b. The appeal shall be investigated and resolved by the pharmacy benefits manager through an internal process within 14 calendar days of receipt of the appeal by the pharmacy benefits manager;
c. A telephone number at which a pharmacy services administrative organization, or a pharmacy may contact the pharmacy benefits manager and speak with an individual who is involved in the appeals process; and
d. (1) If the appeal is denied, the pharmacy benefits manager shall:
(a) provide the reason for the denial to the pharmacy services administrative organization and its contracted pharmacies, and the pharmacy services administrative organization shall inform its contracted pharmacies of the availability, location and pricing of the appealed drug in the State;
(b) provide the reason for the denial directly to a pharmacy, if it contracts directly with a pharmacy benefits manager;
(c) identify the national drug code of a drug product that is available for purchase by the specific contracted pharmacy appealing the claim in this State from wholesalers registered pursuant to P.L.1961, c.52 (C.24:6B-1 et seq.) 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 or the brand effective rate, generic effective rate or other pricing for the appealed drug as determined by the pharmacy benefits manager; and
(d) provide the name of wholesalers registered under P.L.1961, c.52 (C.24:6B-1 et seq.) from which the appealing pharmacy can obtain the brand or multiple source generic drug at or below the brand effective rate, generic effective rate, dispensing fee effective rate, maximum allowable cost or any other pricing formula for pharmacy reimbursement;
(2) If the appeal is approved, the pharmacy benefits manager shall make the price correction, permit the reporting pharmacy to reverse and rebill the appealed claim, and make the price correction effective for all similarly situated pharmacies from the date of the approved appeal.
e. A pharmacy benefits manager shall not terminate a pharmacy licensed in the State of New Jersey solely on the basis that the pharmacy offers and provides store direct delivery and mail prescriptions to an insured as an ancillary service.
L.2015, c.179, s.4; mended 2019, c.274, s.4.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27F-5 - Rules, regulations.

17B:27F-5 Rules, regulations.
5. The Commissioner of Banking and Insurance shall adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations, including any penalty provisions the commissioner deems to be necessary, to effectuate the purposes of this act.
L.2015, c.179, s.5.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27F-6 - Regulations, pharmacy benefits managers.

17B:27F-6 Regulations, pharmacy benefits managers.
1. a. A pharmacy benefits manager, in connection with any contract or arrangement with a private health insurer, prescription benefit plan, or the State Health Benefits Program or School Employees' Health Benefits Program, shall not require a covered person to make a payment at the point of sale for any amount for a deductible, coinsurance payment, or a copayment for a prescription drug benefit in an amount that exceeds the amount permitted pursuant to subsection d. of section 3 of P.L.2023, c.107 (C.17B:27F-3.1).
b. A pharmacy benefits manager shall not prohibit a network pharmacy from, and shall not apply a penalty or any other type of disincentive to a network pharmacy for:
(1) disclosing to a covered person lower cost prescription drug options, including those that are available to the covered person if the covered person purchases the prescription drug without using health insurance coverage;
(2) providing a covered person with the option of paying the pharmacy provider's cash price for the purchase of a prescription drug and not filing a claim with the covered person's health benefits plan if the cash price is less than the covered person's cost-sharing amount; or
(3) providing information to a State or federal agency, law enforcement agency, or the department when such information is required by law.
c. Any provision of a contract that conflicts with the provisions of subsection b. of this section shall be void and unenforceable.
d. A violation of this section shall be an unlawful practice and a violation of P.L.1960, c.39 (C.56:8-1 et seq.), and shall also be subject to any enforcement action that the Commissioner of Banking and Insurance is authorized to take pursuant to section 5 of P.L.2015, c.179 (C.17B:27F-5).
L.2019, c.257, s.1; amended 2023, c.107, s.10.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27F-7 - "Clean Claim" made by a pharmacy, actions of pharmaceutical benefits managers.

17B:27F-7 "Clean Claim" made by a pharmacy, actions of pharmaceutical benefits managers.
1. a. After the date of receipt of a clean claim for payment made by a pharmacy, a pharmacy benefits manager shall not retroactively reduce 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 pharmacy benefits manager and the pharmacy. When a pharmacy adjudicates a claim at the point of sale, the reimbursement amount provided to the pharmacy by the pharmacy benefits manager shall 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 pharmacy benefits manager, and the pharmacy services administration organization, or a pharmacy.
b. For the purpose of this section, "clean claim" means a claim that has no defect or impropriety, including a lack of any required substantiating documentation, or other circumstance requiring special treatment, including, but not limited to, those listed in subsection d. of this section, that prevents timely payment from being made on the claim.
c. A pharmacy benefit manager shall not recoup funds from a pharmacy in connection with claims for which the pharmacy has already been paid unless the recoupment is:
(1) otherwise permitted or required by law;
(2) the result of an audit, performed pursuant to a contract between the pharmacy benefits manager and the pharmacy; or
(3) the result of an audit, performed pursuant to a contract between the pharmacy benefits manager and the designated pharmacy services administrative organization.
d. The provisions of this section shall not apply to an investigative audit of pharmacy records when:
(1) fraud, waste, abuse or other intentional misconduct is indicated by physical review or review of claims data or statements; or
(2) other investigative methods indicate a pharmacy is or has been engaged in criminal wrongdoing, fraud or other intentional or willful misrepresentation.
L.2019, c.274, s.1.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27F-8 - Commissioner review, approval.

17B:27F-8 Commissioner review, approval.
5. The Commissioner of Banking and Insurance may review and approve the compensation program of a pharmacy benefits manager with a health benefits plan to ensure that the reimbursement for pharmacist services paid to a pharmacist or pharmacy is fair and reasonable to provide an adequate pharmacy benefits manager network for a health benefits plan.
L.2019, c.274, s.5.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27F-9 - Applicability of C.17B:27F-1 et seq.

17B:27F-9 Applicability of C.17B:27F-1 et seq.
6. The licensing requirements of P.L.2015, c.179 (C.17B:27F-1 et seq.) shall apply to all pharmacy benefits managers operating in the State of New Jersey. Requirements imposed on carriers by the provisions of P.L.2015, c.179 (C.17B:27F-1 et seq.) shall not apply to an agreement by a pharmacy benefits manager to administer prescription drug benefits on behalf of the State Health Benefits Program, the School Employees Health Benefits Program, the State Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), or a self-insured health benefits plan governed by the provisions of the federal "Employee Retirement Income Security Act of 1974," 29 U.S.C., ss.1001 et seq.
L.2019, c.274, s.6; amended 2023, c.107, s.11.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27F-10 - Violations, penalties.

17B:27F-10 Violations, penalties.
7. a. A pharmacy benefits manager that violates any provision of P.L.2015, c.179 (C.17B:27F-1 et seq.) shall be subject to a penalty in an amount not exceeding the greater of:
(1) a penalty of $5,000 for a first violation and a penalty of $10,000 for each subsequent violation; or
(2) the aggregate gross receipts attributable to all violations.
b. In addition to any other penalties permitted by law, the Commissioner of Banking and Insurance may require a pharmacy benefits manager that violates the provisions of P.L.2015, c.179 (C.17B:27F-1 et seq.) to make restitution and pay compensatory damages, in an amount to be determined by the commissioner, to any person injured by the violation.
L.2019, c.274, s.7; amended 2023, c.107, s.12.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:28-1 - Definition

17B:28-1. Definition
When used in this chapter, the following terms shall have the following respective meanings: a. "Separate account contract" means any contract issued by an insurer under which amount (including without limitation proceeds applied under optional modes of settlement or under dividend options) are allocated by the insurer to one or more separate accounts; b. "Separate account" means any segregated portfolio of investments or designated account of an insurer established pursuant to this chapter; c. "Contract on a variable basis" means any separate account contract providing for the dollar amount of life insurance or annuity benefits or other contractual payments or values thereunder to vary so as to reflect investment results of one or more separate accounts in which amounts with respect to any such contracts shall have been placed; and d. "Variable contract account" means any such separate account.
L.1971, c. 144, s. 17B:28-1. Amended by L.1977, c. 37, s. 1, eff. March 10, 1977.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:28-2 - Qualification of insurer

17B:28-2. Qualification of insurer
No present or future domestic insurer shall undertake the issuance of any contract on a variable basis, and no foreign or alien insurer heretofore or hereafter admitted to transact in this State any class or classes of insurance authorized by this code shall undertake the issuance or delivery of any contract on a variable basis within this State, unless said insurer shall have the authority to write life insurance or annuities or both and until said insurer has satisfied the commissioner that it has been engaged in transacting the business of life insurance for a period of at least 2 years and that its condition or methods of operation in connection with the issuance of such contracts on a variable basis will not be such as would render its operation hazardous to the public or its policyholders in this State. In determining the qualification of an insurer requesting authority to issue or deliver contracts on a variable basis within this State, the commissioner will consider, among other things, the history of the insurer; the character, responsibility and general fitness of the officers and directors of the insurer; and the regulation of such insurer by its jurisdiction of domicile. If the insurer is a subsidiary of an authorized insurer, or affiliated with such authorized insurer by common management or ownership, it may be deemed by the commissioner to have satisfied the aforementioned provisions if either it or such authorized insurer satisfies said provisions.
L.1971, c. 144, s. 17B:28-2.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:28-4 - Required statements; procedure

17B:28-4. Required statements; procedure
Any contract on a variable basis delivered or issued for delivery in this State, and any certificate evidencing variable benefits issued pursuant to any such contract on a group basis, shall contain a statement of the essential features of the procedure to be followed by the insurer in determining the dollar amount of variable benefits or other contractual payments or values thereunder and shall state in clear terms that such amount may decrease or increase according to such procedure. Any such contract delivered or issued for delivery in this State, and any such certificate, shall contain on its first page, in a prominent position, a clear statement that the benefits or other contractual payments or values thereunder are on a variable basis.
L.1971, c. 144, s. 17B:28-4.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:28-6 - Administration

17B:28-6. Administration
Any insurer maintaining one or more separate accounts shall submit annually to the commissioner a report of the business of its separate accounts. Such report shall be made either by a separate annual statement for such business or by suitable additions to such insurer's regular annual statement, in either case on a form prescribed by the commissioner, and shall include details as to all of the income, disbursements, assets and liability items associated with the separate accounts.
The commissioner shall make a separate valuation of the assets of the separate accounts and a copy of such valuation shall be filed in the commissioner's office as a public document. Such valuation shall be in accordance with section 17B:28-10.
The commissioner shall further prescribe by regulation the steps to be taken by the insurer in disposing of those holdings which at any time subsequent to purchase fail to meet the standards and regulations for new investments.
L.1971, c. 144, s. 17B:28-6. Amended by L.1977, c. 37, s. 4, eff. March 10, 1977.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:28-7 - Separate accounts; approval by commissioner

17B:28-7. Separate accounts; approval by commissioner
17B:28-7. Separate accounts; approval by commissioner. Any present or future domestic insurer shall have authority to establish and operate one or more separate accounts and to issue separate account contracts, whether or not contracts on a variable basis, with the approval of the commissioner, and the issuance or delivery of such contracts in this State by any foreign or alien insurer shall be subject to like approval. The commissioner, in granting or withholding any such approval, shall consider in addition to the matters referred to in N.J.S.17B:28-2, 17B:28-5, and 17B:28-15, if applicable, the following:
a. The type or types of contracts the funds from which will be placed in the separate accounts;
b. The extent to which, if any, the dollar amount of benefits or other contractual payments or values under such contracts will be guaranteed;
c. The investment limitations that will be applicable to the separate account;
d. The manner of valuing the assets of the account and the method or methods to be used to compute the liabilities arising from the contracts described in subsection a. of this section;
e. If such contracts are annuity contracts, whether or not they will be participating; and
f. Such other matters as the commissioner shall deem relevant.
Any such approval by the commissioner may be subject to such conditions as he may impose as being necessary for the protection of the public or of such insurer's policyholders. Any approval by the commissioner pursuant to this section may be granted with respect to a single separate account or a class of separate accounts having common characteristics.
For any separate account established and maintained solely for one or more employer group contracts sold to fund an employee benefit plan, which contracts constitute group contracts for the purposes of paragraph (v) of subsection a. of N.J.S.17B:28-9, an insurer may establish and maintain such account 45 days after filing its request for the commissioner's approval, unless within that time the commissioner shall have approved or disapproved the account, provided that neither the insurer nor any such contract shall provide a guaranty, including any index guaranty, of the dollar amount of benefits or other contractual payments or values under such contract. Any disapproval shall state in writing the grounds therefor in such detail as reasonable to inform the insurer thereof. The disapproval by the commissioner of any such account may be on the ground that the account is contrary to law or the public policy of this State. Any disapproval shall be subject to review in accordance with the procedure set forth in the "Administrative Procedure Act," P.L.1968, C.410 (C.52:14B-1 et seq.), and any rules or regulations adopted thereunder.
L.1971, c.144; amended 1977, c.37, s.5; 1989,c.267,s.4.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:28-8 - Amounts placed in account; liabilities

17B:28-8. Amounts placed in account; liabilities
Except as may be otherwise specifically provided by the contract, all amounts with respect to any contract on a variable basis shall be placed in the variable contract account designated in such contract, and all liabilities on any such contract shall be set up in said account.
L.1971, c. 144, s. 17B:28-8. Amended by L.1977, c. 37, s. 6, eff. March 10, 1977.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:28-10 - Valuation of assets

17B:28-10. Valuation of assets
Except as the commissioner may require or permit a different basis of valuation, the valuation of separate account assets for all purposes, including annual reports of the insurer to the commissioner, shall be determined in accordance with the market value of such assets notwithstanding the application of other valuation methods to assets of the insurer other than the assets of separate accounts. If there shall be no readily available market for any such assets, their market value may be determined by reference to opinions or estimates based upon reasonably current transactions in similar investments with such adjustments, if any, as shall be deemed appropriate to take into account any dissimilarities in the investment being valued, or such other method as shall reflect what a willing buyer, under no pressure to buy, would pay a willing seller, under no pressure to sell, for such investment. The net asset value of common stock or shares of any investment company which is an open-end company shall be deemed to be the market value thereof. Such valuation may be made as of such valuation dates as the insurer shall establish from time to time, except as otherwise required for such annual reports to the commissioner.
L.1971, c. 144, s. 17B:28-10. Amended by L.1977, c. 37, s. 8, eff. March 10, 1977.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:28-11 - Reserve liability

17B:28-11. Reserve liability
The reserve liability for contracts on a variable basis shall be established by the commissioner pursuant to the requirements of section 17B:19-8 (the Standard Valuation Law) in accordance with actuarial procedures that recognize the variable nature of the benefits provided.
L.1971, c. 144, s. 17B:28-11.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:28-12 - Annuities

17B:28-12. Annuities
Any insurer which establishes one or more variable contract accounts and issues variable annuity contracts may in its discretion, but need not, require in any case the purchase of annuities which provide for benefits of predetermined dollar amount in specified proportions in combination with the purchase of annuities providing for benefits of variable dollar amount.
L.1971, c. 144, s. 17B:28-12.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:28-14 - Regulation of separate account contracts, insurers issuing the same and sales agents

17B:28-14. Regulation of separate account contracts, insurers issuing the same and sales agents
The commissioner shall have the sole and exclusive authority to regulate the issuance and sale of separate account contracts; and such contracts, the insurers which issue them and the agents, solicitors or other persons who sell them shall not be subject to the Uniform Securities Law (1967) (P.L.1967, c. 93) as amended or supplemented, in the issuance or sale of such contracts.
L.1971, c. 144, s. 17B:28-14. Amended by L.1977, c. 37, s. 10, eff. March 10, 1977; L.1981, c. 355, s. 2.