Overview: P.L. 2017, Chapter 28, The New Jersey Substance Use Disorder Law
On February 15, 2017, New Jersey Governor Christie enacted P.L. 2017, Chapter 28, The New Jersey Substance Use Disorder Law, which sets certain coverage requirements for the treatment of substance use disorders and regulates prescriptions of opioid drugs. This law:
- Requires New Jersey insurers to cover inpatient and outpatient treatment of substance use disorders at in-network facilities
- Puts certain restrictions on prior authorization or utilization management for the first 180 days per plan year of medically necessary inpatient and outpatient treatment of substance use disorders
- Places certain restrictions on prescribed opioids, such as a five-day supply limit on initial prescriptions issued by a New Jersey prescriber
Horizon Blue Cross Blue Shield of New Jersey has implemented the requirements of the law into our current programs and prior authorization requirements, effective on new contracts and renewals on and after May 16, 2017.
The following is a high-level overview of substance use disorder coverage implications1:
- Horizon BCBSNJ must be notified of a member’s admission and the initial treatment plan within 48 hours of the member’s admission or initiation of treatment.
- For the first 180 days per plan year of inpatient and outpatient stay, treatment of substance use disorders must be provided when determined to be medically necessary by the member’s licensed physician, psychologist or psychiatrist without any prior authorization or other prospective utilization management requirements.
- Benefits for the first 28 days of treatment (inpatient stay, intensive outpatient and partial hospitalization services) during each plan year must be provided without any prior authorization, retrospective review or concurrent review of medical necessity.
- Covered persons are entitled to 28 days of inpatient care during a plan year and a separate 28 days of intensive outpatient and partial hospitalization care per plan year.
- Benefits for days 29 and after of inpatient care can be subject to concurrent review. A request for approval of inpatient care beyond the first 28 days must be submitted for concurrent review before the expiration of the initial 28-day period.
- Benefits for days 29 and after of intensive outpatient or partial hospitalization services during each plan year cannot be subject to concurrent review.
- After the first 180 days per plan year, Horizon BCBSNJ can make necessity determinations, prior authorization or retrospective review and other utilization management requirements.
- Except in the case of an in-network exception, a person covered under a PPO or POS plan who voluntarily uses an out-of-network provider, will not be entitled to the protections of the law with respect to those out-of-network services.
Please call Horizon Behavioral Health at 1-800-626-2212 for specific coverage information for members.
The following is a high-level overview of pharmacy coverage implications 1:
- Prior authorization and medical necessity determination criteria for Suboxone (buprenorphine/naloxone) and buprenorphine were removed effective March 13, 2017 for all members with Horizon Pharmacy coverage, excluding those that use the Net Results formulary. Prior authorization and medical necessity determination criteria still apply to Medicare Part D (MAPD and PDP) and Medicaid lines of business.
- Benefits for outpatient prescription drugs for substance use disorder must be provided when determined to be medically necessary by the member’s physician, psychologist or psychiatrist without any prior authorization or other prospective utilization management requirements. These include opioid substitutes and other medication-assisted treatments (e.g., the use of medications in combination with counseling and behavioral therapies).
- Pursuant to emergency rules, effective March 1, 2017, all members, including Medicare Advantage, Medicare Prescription (Part D), Medigap, Medicaid and Federal Employee Program® (FEP®) members, who receive an opioid prescription for acute pain from a New Jersey prescriber will be limited to fill a five-day supply with the initial prescription. In addition, any prescription for acute pain must be at the lowest effective dose of an
immediate-release opioid drug.
- “Acute pain” means pain, whether resulting from disease, accidental or intentional trauma, or other cause, that the practitioner reasonably expects to last only a short period of time.
- “Acute pain” does not include chronic pain, pain being treated as part of cancer care, hospice or other end-of-life care, or pain being treated as part of palliative care.
- Effective May 16, 2017, members will pay a cost share that is based on the amount prescribed. This does NOT apply to Medicare Advantage, Medicare Prescription (Part D), Medigap, Medicaid and FEP members.
- Members will pay a cost share that is prorated when they receive their initial prescription for five days of opioids.
- A subsequent prescription for the same opioid within 30 days of the initial
five-day fill will also be prorated if less than a 30-day supply.
Please call the Pharmacy Services number on the back of the member ID card for information on pharmacy coverage.
1Coverage for these services is based on market segment implementation. Please call Horizon Behavioral Health at 1-800-626-2212 to determine what, if any, substance use disorder coverage implications of the law apply to a Horizon BCBSNJ member. Please call the Pharmacy Services number on the back of the member’s ID card for information on a member’s pharmacy coverage. Note: the law applies to all State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP) members, effective May 16, 2017.