10. a. A carrier that uses a prescription drug formulary pursuant to section 9 of P.L.2023, c.194 (C. 17B:27A-19.24a) shall establish a clinically sound and well-communicated exceptions and appeals process, or incorporate into the carrier’s existing appeals process, the requirements of this section.

b. The process shall provide insureds with step-by-step directions to initiate the exceptions and appeals process and, for a prescription drug that is nonpreferred, not require an insured who obtains that prescription drug to pay an amount greater than the cost-sharing tier level associated with the preferred prescription drug if the prescriber determines that therapeutically similar drug is medically inappropriate.

c. A carrier shall show cause before denying payment for a prescription drug when a prescriber has deemed the carrier’s recommended substitute medically inappropriate.

d. An insured may apply to the Independent Health Care Appeals Program established pursuant to section 11 of P.L.1997, c.192 (C. 26:2S-11) to appeal a carrier decision, and the program shall render a decision as promptly as the patient’s condition mandates.

e. The department shall collect information from each carrier subject to this section to conduct an annual evaluation of the exceptions and appeals processes established pursuant to this section with regard to the appropriateness of the burden of the process on consumers and clinicians and the effects on patient health outcomes.

L.2023, c.194, s.10.