The New Jersey Department of Banking and Insurance has adopted final rules outlining requirements for state-regulated insurers to cap certain out-of-pocket costs on critical prescription medications that include insulin, EpiPens and asthma inhalers.
Gov. Phil Murphy previously signed legislation making New Jersey the second state in the nation to cap out-of-pocket costs for asthma inhalers and epinephrine auto-injector devices in addition to capping consumer costs for insulin. DOBI issued guidance to insurers on the requirements last year, and the caps have been implemented.
The final regulations were published in the New Jersey Register on Monday.
“No one should be without access to medications that can improve their lives,” Murphy said. “Capping the costs of these critical prescriptions such as inhalers and EpiPens can have lifesaving consequences for those who depend on them.”
The law extended Medicare’s $35 a month insulin out-of-pocket cap to state-regulated markets and New Jersey public employee plans, including Get Covered New Jersey, the state’s Official Health Insurance Marketplace where residents who do not have health insurance through an employer can shop for private health insurance plans. The law also capped out-of-pocket costs for epinephrine auto-injector devices and asthma inhalers at $25 and $50, respectively, for a one-month supply.
In addition to the these caps, the regulations require carriers, consistent with a 2023 statute known as Grace’s law, to cover the purchase of hearing aids or cochlear implants, remove the age limit on hearing aids and the $1,000 limit on coverage, and expand coverage of the number of hearing aids to one hearing aid for each hearing-impaired ear every 24 months.
Consumers’ out-of-pocket costs are limited to those paid for primary care provider visits and hearing aids, including cochlear implants, which cannot be treated as durable medical equipment for purposes of determining the appropriate cost.
