A5259

An Act concerning anti-obesity medications and supplementing various parts of the statutory law.

Be It Enacted by the Senate and General Assembly of the State of New Jersey:

1. a. The State Health Benefits Commission shall ensure that every contract providing hospital or medical expense benefits, which is purchased by the commission on or after the effective date of this act, shall provide coverage for anti-obesity medications under the following circumstances:

(1) the subscriber has a diagnosis of obesity or an obesity-related medical condition from a duly certified or licensed health care provider;

(2) the subscriber is prescribed the anti-obesity medication by a duly certified or licensed physician, physician’s assistant, or advanced practice nurse within the scope of practice; and

(3) the prescribed anti-obesity medication is dispensed by a retail or mail-order pharmacy approved by the subscriber’s attending physician, physician’s assistant, or advanced practice nurse.

b. As used in this section, “anti-obesity medication” means a prescription medication that has been approved by the United States Food and Drug Administration and is prescribed by a certified or licensed health care provider for the purpose of chronic weight management by an individual who is obese or overweight and has at least one weight-related medical condition.

2. a. The School Employees’ Health Benefits Commission shall ensure that every contract providing hospital or medical expense benefits, which is purchased by the commission on or after the effective date of this act, shall provide coverage for anti-obesity medications under the following circumstances:

(1) the subscriber has a diagnosis of obesity or an obesity-related medical condition from a duly certified or licensed health care provider;

(2) the subscriber is prescribed the anti-obesity medication by a duly certified or licensed physician, physician’s assistant, or advanced practice nurse within the scope of practice; and

(3) the prescribed anti-obesity medication is dispensed by a retail or mail-order pharmacy approved by the subscriber’s attending physician, physician’s assistant, or advanced practice nurse.

3. a. The Medicaid program and the NJ FamilyCare program shall provide coverage for anti-obesity medications under the following circumstances:

(1) the enrollee has a diagnosis of obesity or an obesity-related medical condition from a duly certified or licensed health care provider;

(2) the enrollee is prescribed the anti-obesity medication by a duly certified or licensed physician, physician’s assistant, or advanced practice nurse within the scope of practice; and

(3) the prescribed anti-obesity medication is dispensed by a retail or mail-order pharmacy that is an approved Medicaid pharmacy.

b. The Commissioner of Human Services shall apply for such federal waivers or state plan amendments as are necessary to implement the provisions of this section and to continue to secure federal financial participation for State expenditures under the federal Medicaid program and the Children’s Health Insurance Program.

c. Coverage of anti-obesity medications under the Medicaid program and the NJ FamilyCare program, pursuant to this section, is contingent upon federal approval of the State’s application for a waiver or a state plan amendment under Title XIX of the Social Security Act (42 U.S.C. s.1315 et seq.).

d. As used in this section:

“Anti-obesity medication” means a prescription medication that has been approved by the United States Food and Drug Administration and is prescribed by a certified or licensed health care provider for the purpose of chronic weight management by an individual who is obese or overweight and has at least one weight-related medical condition.

“Enrollee” means an individual who is covered under the Medicaid program or the NJ FamilyCare program.

“Medicaid” means the State Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.).

“NJ FamilyCare means the NJ FamilyCare program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al).

4. The State Treasurer and the Commissioner of Human Services, pursuant to the “Administrative Procedure Act,” P.L.1968, c.410 (C.52:14B-1 et seq.), shall adopt such rules and regulations as may be necessary to implement the provisions of this act.

5. This act shall take effect on the first day of the seventh month next following the date of enactment, except that the State Treasurer and the Commissioner of Human Services may take any anticipatory administrative action in advance thereof as may be necessary for the implementation of this act.

STATEMENT

This bill requires the State Health Benefits Program (SHBP), the School Employees Health Benefits Program (SEHBP), the State Medicaid program, and the NJ FamilyCare program to provide coverage for anti-obesity medications for subscribers or enrollees. It is the intent of the sponsor of the bill to require these State-supported health benefits programs to cover anti-obesity medications in order to reduce the prevalence of, and medical costs associated with, obesity-related health problems.

Health professionals may prescribe anti-obesity medications for use by patients who have obesity-related health problems that have not been mitigated by diet and exercise alone. According to the National Institutes of Health (NIH), studies show that anti-obesity drugs are most effective when taken as part of a lifestyle program that also includes physical activity and healthy eating habits. While weight loss among patients taking anti-obesity medications varies by medication and the individual, the average weight loss among patients taking such medications ranges from five to ten percent of the patient’s starting weight.

According to the NIH, ten Food and Drug Administration approved anti-obesity medications are currently available for adult use in the United States.

Obesity is a chronic disease that affected 28.6 percent of New Jersey residents in 2022, according to the New Jersey State Health Assessment Data (NJSHAD). The United States Centers for Disease Control and Prevention (CDC) defines obesity as being a body mass index (BMI) of 30 or higher. Individuals with obesity are at increased risk for certain diseases and health conditions, including Type 2 diabetes, asthma, sleep apnea, certain types of cancer, high blood pressure, high cholesterol, and stroke.