NJ S3533

Requires step therapy protocols for the State Health Benefits Program (SHBP), School Employees' Health Benefits Program (SEHBP), and Medicaid to be based on clinical practice guidelines developed by independent expert panels using objective data and transparent processes

Mandates that patients be granted step therapy exceptions when the required drug is contraindicated, likely to cause harm, expected to be ineffective, or when all formulary drugs have failed for that patient

Requires managed care organizations and vendors to respond to step therapy exception requests within 24 hours for urgent cases and 72 hours for non-urgent cases

Coverage for approved step therapy exceptions must be authorized for at least 180 days or the duration of therapy, and all exceptions are eligible for patient appeal

Takes effect January 1, 2026, requiring organizations to publish step therapy exception approval/denial statistics online and make clinical review criteria available upon request