Prescription Drug Plans
Member Guidebook
Pensions & Benefits
HP-0506-0624
For the State Health Benets Program (SHBP) and
the School Employees’ Health Benets Program (SEHBP)
Prescription Drug Plans — Member Guidebook June 2024 Page 2
State Health Benets Program School Employees’ Health Benets Program
TABLE OF CONTENTS
Introduction ...............................3
Prescription Drug Plans .....................3
Eligibility ................................3
Plan Benets ............................3
Retail Pharmacy ..........................3
Mail Order Service ........................3
Specialty Pharmaceutical Provider ...........3
Prescription Drug Coverage ..................4
State Employees .........................4
Local Government Employees ...............5
Local Education Employees .................7
Retiree Prescription Drug Coverage ...........8
Medicare Part D ..........................8
State Retirees and
Local Government Retirees —
Non Medicare Advantage Plans ..............8
State Retirees and Local Government
Retirees — Medicare Advantage Plans ........9
Local Education Retirees —
Non Medicare Advantage Plans .............10
Local Education Retirees —
Medicare Advantage Plans ................10
Purchasing Prescription Drugs
at a Pharmacy ............................11
Participating Pharmacies ..................11
Non-Participating Pharmacies ..............11
How to File a Claim for Reimbursement ......11
Compound Claim Processing. . . . . . . . . . . . . . . 11
Home Delivery Program ....................12
How the Home Delivery Program Works ......12
Coverage and Services Provided by
the Prescription Drug Plans .................12
Dispensing Limits ........................12
Utilization Management ...................12
Information about Generic Drugs ............16
What are Generic Drugs? .................16
Who Determines if a Member
Can Receive Generic Drugs? ..............16
Information about Compound Drugs ..........16
What the Prescription Drug Plans
Do Not Cover .............................16
Enrolling in the Prescription Drug Plans ......17
Levels of Coverage ......................17
Employee Coverage. . . . . . . . . . . . . . . . . . . . . . 17
Transfer of Employment ...................17
Leave of Absence. . . . . . . . . . . . . . . . . . . . . . . . 17
When Coverage Ends ....................17
Retiree Coverage ..........................18
COBRA Coverage .........................18
Appeal Procedures ........................19
Claim Appeal ...........................19
Administrative Appeal. . . . . . . . . . . . . . . . . . . . . 19
Required Information .....................19
External Review Procedures ...............19
Non-Urgent External Review ...............19
Urgent External Review ...................20
HIPAA Privacy ............................20
Audit of Dependent Coverage ...............20
Health Care Fraud .........................20
Glossary .................................21
Notice of Privacy Practices to Members .......23
Protected Health Information (PHI) ..........23
Uses and Disclosures of PHI ...............23
Restricted Uses .........................23
Member Rights ..........................24
Questions and Concerns ..................24
Health Benets Contact Information ..........25
Addresses .............................25
Telephone Numbers ......................25
Health Benets Publications ................25
Page 3 June 2024 Prescription Drug Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
INTRODUCTION
The State Health Benets Program (SHBP) was es-
tablished in 1961. It oers medical, prescription drug,
and dental coverage to qualied State and local gov-
ernment public employees, retirees, and eligible de-
pendents. Local employers must adopt a resolution to
participate in the SHBP.
The State Health Benets Commission (SHBC) is the
executive organization responsible for overseeing the
SH BP.
The State Health Benets Program Act is found in the
New Jersey Statutes Annotated, Title 52, Article 14-
17.25 et seq. Rules governing the operation and admin-
istration of the program are found in Title 17, Chapter 9
of the New Jersey Administrative Code.
The School Employees’ Health Benets Program
(SEHBP) was established in 2007. It oers medical,
prescription drug, and dental coverage to qualied lo-
cal education public employees, retirees, and eligible
dependents. Local education employers must adopt a
resolution to participate in the SEHBP.
The School Employees’ Health Benets Commission
(SEHBC) is the executive organization responsible for
overseeing the SEHBP.
The School Employees’ Health Benets Program Act is
found in the New Jersey Statutes Annotated, Title 52,
Article 14-17.46 et seq. Rules governing the operation
and administration of the program are found in Title 17,
Chapter 9 of the New Jersey Administrative Code.
The New Jersey Division of Pensions & Benets
(NJDPB), specically the Health Benets Bureau and
the Bureau of Policy and Planning, are responsible for
the daily administrative activities of the SHBP and the
SEHBP.
The Prescription Drug Plans are administered for the
SHBP and SEHBP by OptumRx, the pharmacy benet
manager for all eligible members. Prescription drugs
are available at designated copayment levels only
when a participating licensed pharmacy is used. A pre-
scription drug plan identication card is provided and
use of the ID card is required to obtain medications at
a participating retail pharmacy for the designated co-
payment.
Every eort has been made to ensure the accuracy
of the Prescription Drug Plans Member Guidebook.
However, State law and the New Jersey Administrative
Code govern the SHBP and SEHBP. If there are dis-
crepancies between the information presented in this
guidebook and/or plan documents and the law, regula-
tions, or contracts, the law, regulations, and contracts
will govern. Furthermore, if you are unsure whether a
drug is covered, contact OptumRx before you receive
services to avoid any denial of coverage issues that
could result.
If, after reading this guidebook, you have any ques-
tions, comments, or suggestions regarding the infor-
mation presented, please write to the New Jersey Di-
vision of Pensions & Benets, P.O. Box 295, Trenton,
NJ 08625-0295, call us at (609) 292-7524, or send an
email to: pensions.nj@treas.nj.gov
PRESCRIPTION DRUG PLANS
Eligibility
The Prescription Drug Plans’ rules of eligibility and
information on maintaining coverage are the same as
those for the SHBP and SEHBP medical plans. Please
refer to the Summary Program Description for addi-
tional eligibility, enrollment, and coverage information
(see the “Health Benets Publications” section for in-
formation on how to obtain this publication). The only
exception is employees of local employers who have
chosen a private prescription drug plan for their em-
ployees rather than one of the SHBP/SEHBP prescrip-
tion drug plans. If your local employer has chosen a
private prescription drug plan, it must be substantial-
ly similar to the prescription drug plans oered by the
SHBP/SEHBP.
Plan Benets
The prescription drug plans can be used at any a par-
ticipating pharmacy, through the OptumRx Home De-
livery Program, or through Optum Specialty, Optum-
Rx’s specialty pharmacy service.
Retail Pharmacy
Normally, retail pharmacy copayment amounts are
for a 30-day supply. However, you may obtain up to a
90-day supply of your prescription drug. To do so, you
must pay two copayments for a 31- to 60-day supply or
three copayments for a 61- to 90-day supply. Additional
information can be found in the “Purchasing Prescrip-
tion Drugs at a Pharmacy” section.
Mail Order Service
Mail order benets are available where participants
can receive up to a 90-day supply of prescription drugs
for one copayment. Additional information about mail
order service can be found in the “Home Delivery Pro-
gram” section.
Specialty Pharmaceutical Provider
Specialty pharmaceuticals are provided through Op-
tum Specialty (OptumRx’s specialty pharmacy), which
is the exclusive provider for specialty pharmaceuticals
for the Employee Prescription Drug Plans.
If your provider has prescribed a specialty pharmaceu-
tical, you will not be able to ll the prescription at a retail
pharmacy. Instead, you should contact Optum Special-
ty at 1-888-341-8579. When calling, identify yourself
as a SHBP or SEHBP member. Optum Specialty will
contact your provider for the prescription and will work
Prescription Drug Plans — Member Guidebook June 2024 Page 4
State Health Benets Program School Employees’ Health Benets Program
with you to arrange a convenient delivery location and
date. Your medication will be shipped directly to your
home, oce, or provider’s oce.
Your mail order service copayment will apply for all
specialty prescriptions; however, keep in mind, some
medications will not or cannot be dispensed in a 90-
day supply.
PRESCRIPTION DRUG COVERAGE
State Employees
The amount that State employees and their eligible de-
pendents pay for prescription drugs is determined by
the medical plan the employee selects.
The State Health Benets Plan Design Committee es-
tablishes the copayment amounts on an annual basis.
In Plan Year 2024, a State employee or dependent will
pay the following copayment amounts:
• If enrolled in NJ DIRECT15/Freedom15 or Horizon
HMO/Aetna HMO, the copayment at a retail phar-
macy for up to a 30-day supply is $3 for gener-
ic drugs; and $10 for brand name drugs without
generic equivalents. The mail order (or specialty
pharmaceutical) copayment for up to a 90-day
supply is $0 for generic drugs; and $15 for brand
name drugs without generic equivalents. For retail
pharmacy brand name drugs with generic equiv-
alents, the member pays the applicable generic
copay plus the cost dierence between the brand
drug and the generic drug. For mail order brand
name drugs with generic equivalents, the member
pays the dierence between the brand name drug
and the generic drug. The annual out-of-pocket
maximum is $1,890 individually/$3,780 for family.
• If enrolled in CWA Unity DIRECT/CWA Unity
Freedom,* CWA Unity DIRECT 2019/CWA Unity
Freedom 2019*, NJDIRECT/Freedom,** NJDI-
RECT 2019/Freedom 2019,** NJ DIRECT1525/
Freedom1525, or Horizon OMNIA/Aetna Liberty
Plus, the copayment at a retail pharmacy for up to
a 30-day supply is $7 for generic drugs; and $16
for brand name drugs without generic equivalents.
The mail order (or specialty pharmaceutical) co-
payment for up to a 90-day supply is $0 for gener-
ic drugs; and $40 for brand name drugs without
generic equivalents. For retail pharmacy brand
name drugs with generic equivalents, the member
pays the applicable generic copayment plus the
cost dierence between the brand name drug and
the generic drug. For mail order brand name drugs
with generic equivalents, the member pays the
dierence between the brand name drug and the
generic drug. The annual out-of-pocket maximum
is $1,890 individually/$3,780 for family.
• If enrolled in NJ DIRECT2030/Freedom2030, the
copayment at a retail pharmacy for up to a 30-day
supply is $3 for generic drugs; and $18 for brand
name drugs without generic equivalents. The
mail order (or specialty pharmaceutical) copay-
ment for up to a 90-day supply is $0 for gener-
ic drugs; and $36 for brand name drugs without
generic equivalents. For retail pharmacy brand
name drugs with generic equivalents, the mem-
ber pays the applicable generic copay plus the
cost dierence between the brand drug and the
generic drug. For mail order brand name drugs
with generic equivalents, the member pays the
dierence between the brand name drug and the
generic drug. The annual out-of-pocket maximum
is $1,890 individually/$3,780 for family. If enrolled
in NJ DIRECT2035/Freedom2035, the copayment
at a retail pharmacy for up to a 30-day supply is
$7 for generic drugs; and $21 for brand name
drugs without generic equivalents. The mail order
(or specialty pharmaceutical) copayment for up to
a 90-day supply is $0 for generic drugs; and $52
for brand name drugs without generic equivalents.
For retail pharmacy brand name drugs with gener-
ic equivalents, the member pays the applicable ge-
neric copay plus the cost dierence between the
brand drug and the generic drug. For mail order
brand name drugs with generic equivalents, the
member pays the dierence between the brand
name drug and the generic drug. For maintenance
prescription drugs, mail order is mandatory under
NJ DIRECT2035/Freedom2035. The annual out-
of-pocket maximum is $1,890 individually/$3,780
for family.
• If enrolled in NJ DIRECT HDLow/Freedom HD-
Low or NJ DIRECT HDHigh/Freedom HDHigh,
the prescription drugs are included in the plan and
are subject to a deductible and coinsurance. This
means that the member pays the full cost of the
medications until the deductible is reached. Once
the deductible is reached, the member pays the
applicable coinsurance until the out-of-pocket
maximum is met.
* This plan is for members covered by the Communications Workers of America (CWA) only. Members hired before July 1, 2019, will be enrolled in CWA Unity DIRECT/
CWA Unity Freedom. Members hired after July 1, 2019, will be enrolled in CWA Unity DIRECT 2019*/CWA Unity Freedom 2019*.
** Members hired before July 1, 2019, will be enrolled in NJ DIRECT/Freedom. Members hired after July 1, 2019, will be enrolled in NJ DIRECT 2019/Freedom 2019.
Page 5 June 2024 Prescription Drug Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
Local Government Employees
The amount that local government employees and their
eligible dependents pay for prescription drugs is deter-
mined by the prescription drug plan option provided by
the employer and the medical plan the employee se-
lects
Local government employers may elect one of the fol-
lowing three options to provide prescription drug bene-
ts to their employees:
1. The Employee Prescription Drug Plan: The
State Health Benets Plan Design Committee es-
tablishes the copayment amounts on an annual
basis.
In Plan Year 2024, a local government employee
or dependent will pay the following copayment
amounts:
• If enrolled in NJDIRECT/Freedom,* or NJDI-
RECT 2019/Freedom 2019,* the copayment at
a retail pharmacy for up to a 30-day supply is $7
for generic; and $16 for preferred brand name
drugs. The mail order (or specialty pharma-
ceutical) copayment for up to a 90-day supply
is $0 for generic drugs; and $40 for preferred
brand name drugs. For retail pharmacy brand
name drugs with generic equivalents, the mem-
ber pays the applicable generic copay plus the
cost dierence between the brand drug and the
generic drug. For mail order brand name drugs
with generic equivalents, the member pays the
dierence between the brand name drug and
the generic drug. The annual out-of-pocket max-
imum is $1,890 individually/$3,780 for family.
• If enrolled in NJ DIRECT10/Freedom10 NJ DI-
RECT15/Freedom15, or Horizon HMO/Aetna
HMO, the copayment at a retail pharmacy for
up to a 30-day supply is $3 for generic drugs;
and $10 for preferred and non-preferred brand
name drugs. The mail order (or specialty phar-
maceutical) copayment for up to a 90-day sup-
ply is $0 for generic drugs; and $15 for preferred
and non-preferred brand name drugs. For retail
pharmacy brand name drugs with generic equiv-
alents, the member pays the applicable gener-
ic copay plus the cost dierence between the
brand drug and the generic drug. For mail order
brand name drugs with generic equivalents, the
member pays the dierence between the brand
name drug and the generic drug. The annual
out-of-pocket maximum is $1,890 individual-
ly/$3,780 for family.
• If enrolled in NJ DIRECT1525/Freedom1525 or
Horizon OMNIA/Aetna Liberty Plus, the copay-
ment at a retail pharmacy for up to a 30-day
supply is $7 for generic drugs; $16 for preferred
brand name drugs; and $35 for non-preferred
brand name drugs. The mail order (or specialty
pharmaceutical) copayment for up to a 90-day
supply is $0 for generic drugs; $40 for preferred
brand name drugs; and $88 for non-preferred
brand name drugs. For retail pharmacy brand
name drugs with generic equivalents, the mem-
ber pays the applicable generic copay plus the
cost dierence between the brand drug and the
generic drug. For mail order brand name drugs
with generic equivalents, the member pays the
dierence between the brand name drug and
the generic drug. The annual out-of-pocket max-
imum is $1,890 individually/$3,780 for family.
• If enrolled in NJ DIRECT2030/Freedom2030,
the copayment at a retail pharmacy for up to
a 30-day supply is $3 for generic drugs; $18
for preferred brand name drugs; and $46 for
non-preferred brand name drugs. The mail or-
der (or specialty pharmaceutical) copayment for
up to a 90-day supply is $0 for generic drugs;
$36 for preferred brand name drugs; and $92
for non-preferred brand name drugs. For retail
pharmacy brand name drugs with generic equiv-
alents, the member pays the applicable gener-
ic copay plus the cost dierence between the
brand drug and the generic drug. For mail order
brand name drugs with generic equivalents, the
member pays the dierence between the brand
name drug and the generic drug. The annual
out-of-pocket maximum is $1,890 individual-
ly/$3,780 for family.
• If enrolled in NJ DIRECT2035/Freedom2035,
the copayment at a retail pharmacy for up to a
30-day supply is $7 for generic drugs; and $21
for preferred brand name drugs without generic
equivalents. The mail order (or specialty phar-
maceutical) copayment for up to a 90-day sup-
ply is $0 for generic drugs; and $52 for preferred
brand name drugs without generic equivalents.
For retail pharmacy brand name drugs with ge-
neric equivalents, the member pays the applica-
ble generic copay plus the cost dierence be-
tween the brand drug and the generic drug. For
mail order brand name drugs with generic equiv-
alents, the member pays the dierence between
the brand name drug and the generic drug. For
maintenance prescriptions, mail order is manda-
tory under NJ DIRECT2035/Freedom2035. The
annual out-of-pocket maximum is $1,890 indi-
vidually/$3,780 for family.
* Members hired before July 1, 2019, will be enrolled in NJ DIRECT/Freedom. Members hired after July 1, 2019, will be enrolled in NJ DIRECT 2019/Freedom 2019.
Prescription Drug Plans — Member Guidebook June 2024 Page 6
State Health Benets Program School Employees’ Health Benets Program
• If enrolled in NJ DIRECT HDLow/Freedom HD-
Low or NJ DIRECT HDHigh/Freedom HDHigh,
the prescription drugs are included in the plan
and are subject to a deductible and coinsurance.
This means that the member pays the full cost of
the medications until the deductible is reached.
Once the deductible is reached, the member
pays the applicable coinsurance until the out-of-
pocket maximum is met.
2. The NJ DIRECT/Freedom Prescription Drug
Plan and Horizon/Aetna HMO Prescription
Drug Plan:
The NJ DIRECT/Freedom Prescription Drug Plan
is available to local government employees en-
rolled in NJ DIRECT/Freedom,* NJ DIRECT 2019/
Freedom 2019,* NJ DIRECT10/Freedom10, NJ
DIRECT15/Freedom15, NJ DIRECT1525/Free-
dom1525, NJ DIRECT2030/Freedom2030, or NJ
DIRECT2035/Freedom2035, when the local pub-
lic employer does not provide either the Employee
Prescription Drug Plan or a private prescription
drug plan. Plan benets are available at a dis-
counted price (eligible pharmacy price) through
participating retail pharmacies, through mail order,
and through specialty pharmacy services.
• Members pay a coinsurance equal to 10 percent
of the eligible pharmacy price when obtained
through a participating retail pharmacy if you are
enrolled in NJ DIRECT/Freedom,* NJ DIRECT
2019/Freedom 2019,* NJ DIRECT10/Free-
dom10, or NJ DIRECT15/Freedom15; 15 percent
of the eligible pharmacy price when obtained
through a participating retail pharmacy if you are
enrolled in NJ DIRECT1525/Freedom1525 or NJ
DIRECT2030/Freedom2030; and 20 percent
of the eligible pharmacy price when obtained
through a participating retail pharmacy if you are
enrolled in NJ DIRECT2035/Freedom2035.
• Prescription drugs are reimbursed at 80 per-
cent of the eligible pharmacy price if you are
enrolled in NJ DIRECT10/Freedom10; 70 per-
cent of the eligible pharmacy price if you are
enrolled in NJ DIRECT15/Freedom15, NJ DI-
RECT1525/Freedom1525, or NJ DIRECT2030/
Freedom2030; or 60 percent if enrolled in
NJ DIRECT2035, when obtained through a
non-participating retail pharmacy. There is a
$100 deductible when using an out-of-network
pharmacy ($200 for NJ DIRECT2030/Free-
dom2030).
• Prescription drugs at a discounted price are
available by mail order through OptumRx’s
Home Delivery Program.
• Specialty pharmacy services also apply and are
provided through Optum Specialty, OptumRx’s
specialty pharmacy.
• The annual out-of-pocket maximum is $800 in-
dividually/$2,000 for family (combined with med-
ical in-network coinsurance maximum) for NJ
DIRECT/Freedom,* or NJ DIRECT 2019/Free-
dom 2019,**; $400 individually/$1,000 for family
(combined with medical in-network coinsurance
maximum) for NJ DIRECT10/Freedom10, NJ
DIRECT15/Freedom15, and NJ DIRECT1525/
Freedom1525; $800 individually/$2,000 for
family (combined with medical in-network coin-
surance maximum) for NJ DIRECT2030/Free-
dom2030; and $2,000 individually/$5,000 for
family (combined with in-network medical coin-
surance maximum) for NJ DIRECT2035/Free-
dom2035.
• For maintenance prescription drugs, mail order
is mandatory under NJ DIRECT2035.
The HMO Prescription Drug Plan is available to
local government employees enrolled in Horizon
HMO/Aetna HMO, when the local public employer
does not provide either the Employee Prescription
Drug Plan or a private prescription drug plan. Plan
benets are available through participating retail
pharmacies, by mail order through OptumRx’s
Home Delivery Program, and from specialty phar-
macy services provided through Optum Specialty,
OptumRx’s specialty pharmacy.
The HMO Prescription Drug Plan features a
three-tier copayment design for prescription drugs
that are prescribed by your Primary Care Physi-
cian (PCP) or a provider to whom your PCP has
referred you.
• If enrolled in Horizon HMO/Aetna HMO, the co-
payment at a retail pharmacy for up to a 30-day
supply is $5 for generic drugs; $10 for preferred
brand name drugs; and $20 for non-preferred
brand name drugs. The mail order (or specialty
pharmaceutical) copayment for up to a 90-day
supply, if authorized by your PCP, is $5 for ge-
neric drugs; $15 for preferred brand name drugs;
and $25 for non-preferred brand name drugs.
For retail pharmacy brand name drugs with
generic equivalents, the member pays the ap-
plicable generic copay plus the cost dierence
between the brand drug and the generic drug.
For mail order brand name drugs with generic
equivalents, the member pays the dierence
between the brand name drug and the generic
drug. Specialty pharmacy services also apply.
The annual out-of-pocket maximum is $1,890
individually/$3,780 for family.
Tiered Plans: If enrolled in Horizon OMNIA/Aetna
Liberty Plus, the copayment at a retail pharmacy
for up to a 30-day supply is $7 for generic drugs;
$16 for preferred brand name drugs; and $35 for
non-preferred brand name drugs. The mail order
(or specialty pharmaceutical) copayment for up to
Page 7 June 2024 Prescription Drug Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
a 90-day supply is $0 for generic drugs; $40 for
preferred brand name drugs; and $88 for non-pre-
ferred brand name drugs. For retail pharmacy
brand name drugs with generic equivalents, the
member pays the applicable generic copay plus
the cost dierence between the brand drug and
the generic drug. For mail order brand name drugs
with generic equivalents, the member pays the
dierence between the brand name drug and the
generic drug. Specialty pharmacy services also
apply.
High Deductible Health Plans (HDHP): If enrolled
in NJ DIRECT HDLow/Freedom HDLow or NJ DI-
RECT HDHigh/Freedom HDHigh, the prescription
drugs are included in the plan and are subject to a
deductible and coinsurance. This means that the
member pays the full cost of the medications until
the deductible is reached. Once the deductible is
reached, the member pays the applicable coinsur-
ance until the out-of-pocket maximum is met.
3. A private (non-SHBP/SEHBP) prescription
drug plan that is at least equal to the Employee
Prescription Drug Plans.
Local Education Employees
The amount that local education employees and eligible
dependents pay for prescription drugs is determined by
the prescription drug plan option provided by the em-
ployer and the employee’s selected medical plan.
Local education employers may elect one of the follow-
ing three options to provide prescription drug benets
to their employees:
1. The Employee Prescription Drug Plan: The
School Employees’ Health Benets Plan Design
Committee establishes the copayment amounts
on an annual basis.
In Plan Year 2024, a local education employee
or dependent will pay the following copayment
amounts:
• If enrolled in NJ DIRECT10/Freedom10 or NJ
DIRECT15/Freedom15, the copayment at a re-
tail pharmacy for up to a 30-day supply is $3
for generic drugs; and $10 for preferred and
non-preferred brand name drugs. The mail order
(or specialty pharmaceutical) copayment for up
to a 90-day supply is $5 for generic drugs; and
$15 for preferred and non-preferred brand name
drugs. The annual out-of-pocket maximum is
$1,890 individually/$3,780 for family.
• If enrolled in the Horizon or Aetna New Jersey
Educators Health Plan (NJEHP) or the Garden
State Health Plan (GSHP),* the copayment at a
retail pharmacy for up to a 30-day supply is $5
for generic drugs; and $10 for preferred brand
name drugs. The mail order (or specialty phar-
maceutical) copayment for up to a 90-day supply
is $10 for generic drugs; and $20 for preferred
brand name drugs. For both retail pharmacy and
mail order non-preferred brand name drugs with
generic equivalents, the member pays the appli-
cable brand copayment plus the cost dierence
between the brand name drug and the gener-
ic drug. The annual out-of-pocket maximum is
$1,600 individually/$3,200 for family.
2. The NJ DIRECT/Freedom Prescription Drug
Plan, the New Jersey Educators Health Plan
(NJEHP) Prescription Drug Plan, and the Gar-
den State Health Plan (GSHP) Prescription
Drug Plan:
The NJ DIRECT/Freedom, NJEHP, and GSHP Pre-
scription Drug Plan is available to local education
employees enrolled in NJ DIRECT10/Freedom10,
NJ DIRECT15/Freedom15, Horizon or Aetna New
Jersey Educators Health Plan, and Garden State
Health Plan, when the local public employer does
not provide either the Employee Prescription Drug
Plan or a private prescription drug plan. Plan ben-
ets are available at a discounted price (eligible
pharmacy price) through participating retail phar-
macies, through mail order, and through specialty
pharmacy services.
• Members pay a coinsurance equal to 10 percent
of the eligible pharmacy price when obtained
through a participating retail pharmacy if you
are enrolled in NJ DIRECT10/Freedom10 or NJ
DIRECT15/Freedom15; for NJEHP and GSHP,
copays are the same as if coverage is through
the SEHBP’s Prescription Drug Plan. For NJ
DIRECT10/Freedom10 and NJ DIRECT15/Free-
dom15, the out of pocket maximum is $400 indi-
vidually/$1,000 for family.
• If enrolled in the NJEHP or the GSHP, the co-
payment at a retail pharmacy for up to a 30-
day supply is $5 for generic drugs; and $10 for
preferred brand name drugs. The mail order (or
specialty pharmaceutical) copayment for up to a
90-day supply is $10 for generic drugs; and $20
for preferred brand name drugs. For both retail
pharmacy and mail order non-preferred brand
name drugs with generic equivalents, the mem-
ber pays the applicable brand copayment plus
the cost dierence between the brand name
drug and the generic drug. The annual out-of-
pocket maximum is $1,600 individually/$3,200
for family.
• Prescription drugs at a discounted price are
available by mail order through OptumRx’s
Home Delivery Program at https://optumrx.
com/stateofnewjersey
*Members hired on or after July 1, 2020, must be enrolled in either the New Jersey Educators Health Plan (NJEHP) or the Garden State Health Plan (GSHP).
Prescription Drug Plans — Member Guidebook June 2024 Page 8
State Health Benets Program School Employees’ Health Benets Program
• Specialty pharmacy services also apply and are
provided through Optum Specialty, OptumRx’s
specialty pharmacy.
3. A private (non-SEHBP) prescription drug plan
that is at least equal to the Employee Prescription
Drug Plans.
RETIREE PRESCRIPTION DRUG COVERAGE
Retirees enrolled in a SHBP or SEHBP medical plan
have access to the Retiree Prescription Drug Plan.
Plan benets are available through participating retail
pharmacies, through mail order, and through special-
ty pharmacy services. The plan features a three-tier
copayment design, except for high deductible health
plans. The copayment that retired members and their
eligible dependents pay for prescription drugs is deter-
mined by the medical plan the retiree selects. Retail
pharmacy services require a copayment for up to a 30-
day supply of prescription drugs. Mail order participants
can receive up to a 90-day supply of prescription drugs
for one mail order copayment. Specialty pharmacy ser-
vices for members not enrolled in Medicare Part D are
provided via mail through Optum Specialty, OptumRx’s
specialty pharmacy. If your provider has prescribed a
specialty pharmaceutical, you will not be able to ll the
prescription at a retail pharmacy.
Medicare Part D
If you are enrolled in the Retired Group of the SHBP/
SEHBP and eligible for Medicare, you will be automat-
ically enrolled in the OptumRx Medicare Prescription
Drug Plan (PDP) — a Medicare Part D Plan.
If you enroll in another Medicare Part D plan, you will
lose your prescription drug benets provided by the
SHBP/SEHBP. However, your medical benets will re-
main in eect.
You may waive the OptumRx Medicare
PDP only if you
are enrolled in another Medicare Part D plan. To re-
quest that your coverage be waived, you must submit
proof of enrollment in another Medicare Part D plan.
If you have previously waived your prescription drug
coverage for another Medicare Part D plan, and you
wish to re-enroll in the OptumRx Medicare PDP, you
must send proof of your termination from the other
Medicare Part D plan. Acceptable proof is a letter from
the other Medicare Part D plan conrming the date
upon which you are disenrolled. We must receive this
proof within 60 days of the termination from the other
Medicare Part D plan.
Eective January 1, 2024, copayment amounts for retir-
ee prescription drug coverage are as follows:
State Retirees and Local Government* Retirees —
Non Medicare Advantage Plans
• If enrolled in NJ DIRECT, the copayment at a retail
pharmacy for up to a 30-day supply is $7 for gener-
ic drugs; $16 for preferred brand name drugs; and
$35 for non-preferred brand name drugs. The mail
order (or specialty pharmaceutical) copayment for
up to a 90-day supply is $18 for generic drugs;
$40 for preferred brand name drugs; and $88 for
non-preferred brand name drugs. For both retail
pharmacy and mail order brand name drugs with
generic equivalents, the member pays the applica-
ble generic copay, plus the cost dierence between
the brand drug and the generic drug. The out-of-
pocket maximum is $1,351 per person/$2,702 for
family.
• If enrolled in NJ DIRECT10/Freedom10** or NJ
DIRECT15/Freedom15,** the copayment at a retail
pharmacy for up to a 30-day supply is $10 for ge-
neric drugs; $22 for preferred brand name drugs;
and $44 for non-preferred brand name drugs. The
mail order (or specialty pharmaceutical) copay-
ment for up to a 90-day supply is $5 for generic
drugs; $28 for preferred brand name drugs; and
$55 for non-preferred brand name drugs. For both
retail pharmacy and mail order brand name drugs
with generic equivalents, the member pays the
applicable generic copay, plus the cost dierence
between the brand drug and the generic drug. The
annual out-of-pocket maximum is $1,351 per per-
son/$2,702 for family.
• If enrolled in Horizon HMO/Aetna HMO, the copay-
ment at a retail pharmacy for up to a 30-day sup-
ply is $6 for generic drugs; $12 for preferred brand
name drugs; and $24 for non-preferred brand
name drugs. The mail order (or specialty pharma-
ceutical) copayment for up to a 90-day supply is
$5 for generic drugs; $18 for preferred brand name
drugs; and $30 for non-preferred brand name
drugs. For both retail pharmacy and mail order
brand name drugs with generic equivalents, the
member pays the applicable generic copay, plus
the cost dierence between the brand drug and
the generic drug. The annual out-of-pocket max-
imum is $1,351 per person/$2,702 for family.
• If enrolled in NJ DIRECT1525/Freedom1525 or
Horizon HMO125/Aetna HMO1525, the copay-
ment at a retail pharmacy for up to a 30-day sup-
ply is $7 for generic drugs; $16 for preferred brand
name drugs; and $35 for non-preferred brand
* These copays do not apply to retirees of local government employers who have a private prescription plan.
** Medicare-eligible retirees cannot enroll in NJ DIRECT10/Freedom10, NJ DIRECT15/Freedom15, Horizon OMNIA/Aetna Liberty Plus, or the High Deductible Health
Plans.
Page 9 June 2024 Prescription Drug Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
name drugs. The mail order (or specialty pharma-
ceutical) copayment for up to a 90-day supply is
$5 for generic drugs; $40 for preferred brand name
drugs; and $88 for non-preferred brand name
drugs. For both retail pharmacy and mail order
brand name drugs with generic equivalents, the
member pays the applicable generic copay, plus
the cost dierence between the brand drug and
the generic drug. The out-of-pocket maximum is
$1,351 per person/$2,702 for family.
• If enrolled in NJ DIRECT2030/Freedom2030 or Hori-
zon HMO2030/Aetna HMO2030, the copayment at
a retail pharmacy for up to a 30-day supply is $3
for generic drugs; $18 for preferred brand name
drugs; and $46 for non-preferred brand name
drugs. The mail order (or specialty pharmaceu-
tical) copayment for up to a 90-day supply is $5
for generic drugs; $36 for preferred brand name
drugs; and $92 for non-preferred brand name
drugs. For both retail pharmacy and mail order
brand name drugs with generic equivalents, the
member pays the applicable generic copay, plus
the cost dierence between the brand drug and
the generic drug. The out-of-pocket maximum is
$1,351 per person/$2,702 for family.
• If enrolled in Horizon OMNIA/Aetna Liberty
Plus,** the copayment at a retail pharmacy for
up to a 30-day supply is $7 for generic drugs;
$16 for preferred brand name drugs; and $35 for
non-preferred brand name drugs. The mail order
(or specialty pharmaceutical) copayment for up to
a 90-day supply is $18 for generic drugs; $40 for
preferred brand name drugs; and $88 for non-pre-
ferred brand name drugs. For both retail pharma-
cy and mail order brand name drugs with generic
equivalents, the member pays the applicable ge-
neric copay, plus the cost dierence between the
brand drug and the generic drug. The out-of-pock-
et maximum is $1,351 per person/$2,702 for family.
• If enrolled in NJ DIRECT HDLow/Freedom HD-
Low** or NJ DIRECT HDHigh/Freedom HDHigh,**
the prescription drugs are included in the medi-
cal plan and are subject to a deductible and co-
insurance. This means that the member pays the
full cost of the medications until the deductible
is reached. Once the deductible is reached, the
member pays the applicable coinsurance until the
out-of-pocket maximum is met.
• For State retirees who were covered by cer-
tain negotiated labor groups and those who
were non-aligned — If enrolled in CWA Unity
DIRECT/CWA Unity Freedom* or NJ DIRECT/
Freedom,* the copayment at a retail pharmacy
for up to a 30-day supply is $7 for generic drugs;
$16 for preferred brand name drugs; and $35 for
non-preferred brand name drugs. The mail order
(or specialty pharmaceutical) copayment for up to
a 90-day supply is $18 for generic drugs; $40 for
preferred brand name drugs; and $88 for non-pre-
ferred brand name drugs. For both retail pharma-
cy and mail order brand name drugs with generic
equivalents, the member pays the applicable ge-
neric copay, plus the cost dierence between the
brand drug and the generic drug. The out-of-pock-
et maximum is $1,351 per person/$2,702 for family.
State Retirees and Local Government Retirees —
Medicare Advantage Plans
• If enrolled in Medicare Advantage PPO ESA 10
or Medicare Advantage PPO ESA 15, the co-
payment at a retail pharmacy for up to a 30-day
supply is $10 for generic drugs; $22 for preferred
brand name drugs; and $44 for non-preferred
brand name drugs. The mail order (or specialty
pharmaceutical) copayment for up to a 90-day
supply is $5 for generic drugs; $28 for preferred
brand name drugs; and $55 for non-preferred
brand name drugs. The annual out-of-pocket
maximum is $1,351 per person/$2,702 for family.
• If enrolled in Medicare Open Access HMO, the co-
payment at a retail pharmacy for up to a 30-day
supply is $6 for generic drugs; $12 for preferred
brand name drugs; and $24 for non-preferred
brand name drugs. The mail order (or specialty
pharmaceutical) copayment for up to a 90-day
supply is $5 for generic drugs; $18 for preferred
brand name drugs; and $30 for non-preferred
brand name drugs. The annual out-of-pocket max-
imum is $1,351 per person/$2,702 for family.
• If enrolled in Medicare Open Access HMO 1525,
the copayment at a retail pharmacy for up to
a 30-day supply is $7 for generic drugs; $16 for
preferred brand name drugs; and $35 for non-pre-
ferred brand name drugs. The mail order (or
specialty pharmaceutical) copayment for up to
a 90-day supply is $5 for generic drugs; $40 for
preferred brand name drugs; and $88 for non-pre-
ferred brand name drugs. The annual out-of-pock-
et maximum is $1,351 per person/$2,702 for family
* Medicare-eligible retirees cannot enroll in CWA Unity DIRECT/CWA Unity Freedom, NJ DIRECT/Freedom, the NJEHP, or the GSHP.
** Medicare-eligible retirees cannot enroll in NJ DIRECT10/Freedom10, NJ DIRECT15/Freedom15, Horizon OMNIA/Aetna Liberty Plus, or the High Deductible Health
Plans.
Prescription Drug Plans — Member Guidebook June 2024 Page 10
State Health Benets Program School Employees’ Health Benets Program
Local Education Retirees —
Non Medicare Advantage Plans
• If enrolled in the New Jersey Educators Health
Plan (NJEHP) or the Garden State Health Plan,*
the copayment at a retail pharmacy for up to a
30-day supply is $5 for generic drugs and $10 for
preferred name brand drugs. The mail order (or
specialty pharmaceutical) copayment for up to a
90-day supply is $10 for generic drugs and $20 for
preferred brand name drugs. For both retail phar-
macy and mail order non-preferred brand name
drugs with generic equivalents, the member pays
the applicable brand copayment, plus the cost dif-
ference between the brand drug and the generic
equivalent.
Note: Local education retirees who are not eligible
for Medicare must enroll in the New Jersey Educators
Health Plan (NJEHP) or the Garden State Health Plan
(GSHP).
• If enrolled in Aetna HMO, the copayment at a retail
pharmacy for up to a 30-day supply is $6 for ge-
neric drugs; $13 for preferred brand name drugs;
and $26 for non-preferred brand name drugs. The
mail order (or specialty pharmaceutical) copay-
ment for up to a 90-day supply is $5 for generic
drugs; $19 for preferred brand name drugs; and
$31 for non-preferred brand name drugs. The
annual out-of-pocket maximum is $1,411 per per-
son/$2,822 for family.
• If enrolled in/Freedom1525 or Aetna HMO1525,
the copayment at a retail pharmacy for up to a 30-
day supply is $7 for generic drugs; $17 for pre-
ferred brand name drugs; and $36 for non-pre-
ferred brand name drugs. The mail order (or
specialty pharmaceutical) copayment for up to
a 90-day supply is $5 for generic drugs; $41 for
preferred brand name drugs; and $91 for non-pre-
ferred brand name drugs. The annual out-of-
pocket maximum is $1,411 per person/$2,822 for
family.
• If enrolled in Freedom2030 or Aetna HMO2030, the
copayment at a retail pharmacy for up to a 30-day
supply is $3 for generic drugs; $19 for preferred
brand name drugs; and $48 for non-preferred
brand name drugs. The mail order (or specialty
pharmaceutical) copayment for up to a 90-day
supply is $5 for generic drugs; $37 for preferred
brand name drugs; and $95 for non-preferred
brand name drugs. The annual out-of-pocket
maximum is $1,411 per person/$2,822 for family.
Note: Aetna HMO, Freedom1525, Aetna HMO1525,
Freedom2030, and Aetna HMO2030 are only avail-
able to Medicare-eligible members as a supplement
to Medicare.
Local Education Retirees —
Medicare Advantage Plans
• If enrolled in Medicare Advantage PPO ESA 10
or Medicare Advantage PPO ESA 15, the copay-
ment at a retail pharmacy for up to a 30-day supply
is $10 for generic drugs; $21 for preferred brand
name drugs; and $42 for non-preferred brand
name drugs. The mail order (or specialty phar-
maceutical) copayment for up to a 90-day supply
is $5 for generic drugs; $31 for preferred brand
name drugs; and $52 for non-preferred brand
name drugs. The annual out-of-pocket maximum
is $1,411 per person/$2,822 for family.
• If enrolled in Medicare Open Access HMO, the
copayment at a retail pharmacy for up to a 30-day
supply is $6 for generic drugs; $13 for preferred
brand name drugs; and $26 for non-preferred
brand name drugs. The mail order (or specialty
pharmaceutical) copayment for up to a 90-day
supply is $5 for generic drugs; $19 for preferred
brand name drugs; and $31 for non-preferred
brand name drugs. The annual out-of-pocket
maximum is $1,411 per person/$2,822 for family.
• If enrolled in Medicare Open Access HMO 1525,
the copayment at a retail pharmacy for up to a 30-
day supply is $7 for generic drugs; $17 for pre-
ferred brand name drugs; and $36 for non-pre-
ferred brand name drugs. The mail order (or
specialty pharmaceutical) copayment for up to
a 90-day supply is $5 for generic drugs; $41 for
preferred brand name drugs; and $91 for non-pre-
ferred brand name drugs. The annual out-of-
pocket maximum is $1,411 per person/$2,822 for
family.
* Medicare-eligible retirees cannot enroll in the NJEHP, or the GSHP.
Page 11 June 2024 Prescription Drug Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
PURCHASING PRESCRIPTION DRUGS
AT A PHARMACY
To purchase a prescription drug at a retail pharmacy,
present your identication card and prescription to the
pharmacist. Prescription drug rells are also covered
as long as the prescription is used within one year of
the original prescription date, authorized by your pro-
vider, and permitted by law.
Participating Pharmacies
Almost all New Jersey pharmacies have elected to
participate with the Prescription Drug Plans oered
through OptumRx. To identify a participating pharmacy
in your area, active employees and non-Medicare-eli-
gible retirees may call 1-844-368-8740. Medicare-eli-
gible retirees may call 1-844-368-8765 or check online
at: http://optumrx.com/stateofnewjersey
When using a participating pharmacy, present your
identication card and prescription. The pharmacist will
complete the transaction and process your prescrip-
tion. The submission of a claim form is not required.
You will be asked only to pay the appropriate copay-
ment/coinsurance for any covered medication.
If you have forgotten your identication card, or are
waiting for a new one, request your pharmacist to con-
rm coverage by entering “STATENJ” as your group
number and contacting OptumRx Pharmacy Services
Help Desk to obtain your OptumRx ID number. Oth-
erwise, you may have to pay the full cost of the pre-
scription drug to the pharmacist. However, you will still
be entitled to the benets of this plan. Simply obtain
a detailed pharmacy receipt for each prescription and
forward it along with a claim form to OptumRx for reim-
bursement. Your reimbursement will be based on the
participating pharmacy allowance less your copayment
(see the “How to File a Claim for Reimbursement” sec-
tion).
Non-Participating Pharmacies
Over 60,000 pharmacies participate with OptumRx;
however, some pharmacies in New Jersey and in oth-
er states do not have agreements with OptumRx and
are not part of the Employee Prescription Drug Plans.
When using a non-participating pharmacy, you will be
asked to pay the full cost of the prescription drug to the
pharmacist. You then must le a claim for reimburse-
ment with OptumRx.
Your reimbursement will be based on the participat-
ing pharmacy allowance for the cost of the medication
less your copayment. If the non-participating pharma-
cy charges more than the allowance for a participating
pharmacy, you will not be reimbursed for the dierence.
How to File a Claim for Reimbursement
1. If you have to le a claim for reimbursement, obtain
a detailed pharmacy receipt for each prescription
which includes the following:
• Patient’s rst and last name;
• Prescription number;
• Date the prescription was lled;
• Name, address, and NABP number of the
pharmacy;
• National Drug Code (NDC) number;
• Name and strength of the drug or NDC number;
• Quantity and form;
• Days of supply;
• “Dispense as written” or “Substituted for”;
• Provider’s name and Drug Enforcement Admin-
istration (DEA) number; and
• Cost of the prescription drug.
2. Obtain a Prescription Drug Reimbursement Form
by calling OptumRx Member Services at: 1-844-
368-8740 (for active employees and non-Medi-
care-eligible retirees) or 1-844-368-8765 (for
Medicare-eligible retirees).
3. Send the completed Prescription Drug Reimburse-
ment Form, along with your pharmacy receipt(s), to
the address on the claim form.
Claims should be led as soon as possible. The ling
deadline is one year following the end of the calendar
year of the dispensing date. Information about claims or
coverage can be obtained by calling OptumRx.
Compound Claim Processing
The following information is needed to process a com-
pound claim:
• List the valid 11-digit NDC number for each ingre-
dient used for the compound prescription.
• For each NDC number, indicate the metric quantity
expressed in the number of tablets, grams, millili-
ters, creams, ointments, injectables, etc.
• For each NDC number, indicate cost per ingredi-
ent.
• Indicate the total charge (dollar amount) paid by
the patient.
• Receipt(s) must be attached to claim form.
Each ingredient is used in the calculation of the total
reimbursement for the compound claim. It is important
to provide all items contained in the compound listed
above in order to ensure your claim is processed cor-
rectly.
Prescription Drug Plans — Member Guidebook June 2024 Page 12
State Health Benets Program School Employees’ Health Benets Program
HOME DELIVERY PROGRAM
OptumRx’s Home Delivery Program is designed for par-
ticipants who require medication on an ongoing basis to
treat chronic health conditions such as high blood pres-
sure, asthma, or diabetes, for example. These types
of prescriptions are often referred to as maintenance
drugs. All home delivery prescriptions are lled by reg-
istered pharmacists who are available for emergency
consultations 24 hours a day, seven days a week by
contacting OptumRx Member Services at 1-844-368-
8740 (for active employees and non-Medicare-eligible
retirees) or 1-844-368-8765 (for Medicare-eligible re-
tirees).
How the Home Delivery Program Works
When you order maintenance drugs that you take on a
regular basis through OptumRx’s Home Delivery Pro-
gram, you get larger quantities of medication at one
time – up to a 90-day supply for only one copayment
per prescription.
If you have an immediate need for your initial prescrip-
tion, it is suggested that you ask your provider to issue
you two prescriptions — one for a 90-day supply of
needed medications plus rells, the second for a 30-day
supply of medication. The 30-day prescription should
be lled at your local pharmacy for your use while your
home delivery prescription is being processed.
Contact OptumRx Member Services at 1-844-368-
8740 (for active employees and non-Medicare-eligible
retirees) or 1-844-368-8765 (for Medicare-eligible retir-
ees) or on their website: https://optumrx.com/stateof-
newjersey for more information on their Home Delivery
Program.
Note: Prescriptions for certain perishable drugs and
those sensitive to heat and cold should be processed
at a participating pharmacy nearest your home. If pro-
cessed through OptumRx’s Home Delivery Program or
Optum Specialty, OptumRx’s specialty pharmacy, you
will be advised prior to shipment of the mailing date to
ensure someone is home to receive the delivery.
COVERAGE AND SERVICES PROVIDED
BY THE PRESCRIPTION DRUG PLANS
Your Prescription Drug Plan helps meet the cost of
drugs prescribed for you and your covered dependents
for use outside of hospitals, skilled nursing facilities, or
other institutions. As required by Federal Law, covered
drugs can be dispensed only upon a written prescrip-
tion ordered by a provider.
The following are covered benets unless listed as an
exclusion:
• Federal legend drugs;
• Insulin;
• Oral and injectable contraceptives and contracep-
tive patches. The Patient Protection and Aordable
Care Act (PPACA) requires certain women’s pre-
ventive services to be covered with no cost sharing.
All Food and Drug Administration (FDA)-approved
generic prescription contraceptives and brand
name prescription contraceptives without generic
equivalents have no copayment. Brand name pre-
scription contraceptives with generic equivalents
are charged the applicable brand name copay-
ment;
Note: If your prescriber believes that the generic
equivalent is not appropriate, please contact Op-
tumRx for an exception at 1-844-368-8740 (for ac-
tive employees and non-Medicare-eligible retirees)
or 1-844-368-8765 (for Medicare-eligible retirees).
• Infertility drugs;
• Over-the-counter diabetic supplies, including test
kits and test strips;
• Disposable needles and syringes for diabetic use
only; and
• Preventive medications — see the “Preventive
Medications” chart.
Dispensing Limits
The maximum amount of a drug which is allowed to be
dispensed per prescription or rell:
• Retail Pharmacy — up to a 90-day supply (copay-
ment required for each 30-day increment).
• Home Delivery Program — up to a 90-day sup-
ply.
Utilization Management
The Prescription Drug Plans include various procedur-
al and administrative rules and requirements designed
to ensure appropriate prescription drug usage and to
encourage the use of cost-eective drugs. Through
these eorts, plan members benet by obtaining safe
amounts of appropriate prescription drugs in a cost-ef-
fective manner. The following utilization management
programs are part of the Prescription Drug Plans:
• Quantity Management — Limits the maximum
amount of one medication you may receive over a
period of time. Prescription drugs may have a limit
for any of the following reasons:
• Safety;
• Clinical guidelines and prescribing patterns;
• Potential for inappropriate use; and/or
• FDA-approved dosing regimen(s).
Prescription drugs are not eligible to be relled
until 75 percent of the last ordered and dispensed
supply period has passed (i.e., a rell for a 30-day
* PDST does not apply to Medicare-eligible retirees.
Page 13 June 2024 Prescription Drug Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
supply will be honored after 23 days have passed).
Volume restrictions currently apply to certain drugs
such as sexual dysfunction drugs (Viagra, etc.).
• Step Therapy — Requires prior authorization of
certain more costly prescription drugs, where such
drugs have shown no added benet regarding ef-
cacy or side eects over lower-cost therapeutic
alternatives. Step Therapy may require a trial of
lower-cost prescription drugs before approval of
the higher-cost prescription drug, where clinically
appropriate. Step Therapy programs may be used
to monitor the use of new medications that come
on the market (second-line agents) or select clas-
sications of drugs.
• Preferred Drug Step Therapy (PDST)* — Under
PDST, a member is required to try and fail a low-
er-cost prescription drug before approval of a high-
er-cost prescription drug in the following classes
of drugs: Proton Pump Inhibitors (ulcer/reux
drugs), SSRI/SSNRI antidepressants, osteoporo-
sis drugs, nasal steroids, and hypnotics. Standard
copayments apply for prescription drugs approved
under the PDST including higher-cost prescription
drugs that are found to be clinically appropriate.
The “Medications under Preferred Drug Step Ther-
apy (PDST)” chart lists medications that are sub-
ject to PDST. If you ll a prescription for one of the
medications in the rst column without getting prior
approval, you will be responsible for the entire cost
of the drug. If you have tried a medication in the
third column and failed, your provider can request
a coverage review. If coverage is approved, you
will pay the plan’s appropriate copayment for the
medication, which may be higher than what you
would pay for the preferred alternatives. The third
column of the chart lists medications that can treat
the same condition as those in the rst column and
are preferred by your plan. You can ll prescrip-
tions for these medications without a coverage re-
view, and you will pay the appropriate copayment.
Ask your provider whether one of the preferred al-
ternatives may be right for you.
• Dose Optimization Program — A drug utiliza-
tion management process encouraging safe and
appropriate use of once-per-day medications.
Prescriptions are reviewed for multiple daily drug
doses of a lower-strength medication where a
higher-strength, once-daily dose is equally eec-
tive. Dose optimization limits are applied to the
number of pills per day for certain medications,
where the use of multiple pills to achieve a daily
dose is not supported by medical necessity.
• Prior Authorization — A mechanism to screen
a drug class by specic criteria along with a pa-
tient’s medical history to determine if the drug is
covered under the plan. Prior authorization must
be obtained for specic prescription drugs before
they are dispensed to determine if they meet the
eligibility requirements of the plan.
• Member High Utilization Management Pro-
gram — Pharmacy claims (along with supporting
medical data) are evaluated on a periodic basis to
identify, document, and correct or deter cases of
excessive or abusive utilization.
Under certain circumstances, a pharmacy may not
be able to determine, at the point of sale, whether a
prescription drug is covered. For example, the informa-
tion on the prescription order may not be sucient to
determine medical necessity and appropriateness. In
those circumstances, a member may elect to receive a
96-hour supply of the prescription drug, as a covered
benet, until the determination is made. Alternatively,
the member may decide to purchase the prescription
drug and submit a claim for benets. If the claim is de-
nied, no charge in excess of the charge for the 96-hour
supply will be covered for that prescription drug or any
rell(s) of it.
Prescription Drug Plans — Member Guidebook June 2024 Page 14
State Health Benets Program School Employees’ Health Benets Program
Preventive Medications
Drug
Preventive Service
Guidelines Coverage Details
Example
Covered Drugs
Aspirin Aspirin 81mg for prevention of mor-
bidity and mortality from Preeclamp-
sia in pregnant women at risk.
Cover at $0 copay, oral over-the-counter (OTC)
aspirin products (with prescription).
Excluded: prescription aspirin products, non-oral
aspirin products, or aspirin products > 81 mg.
Enteric Coated Aspirin, Children’s Aspirin, Low-
Dose Aspirin, St. Joseph Aspirin, Bayer Children’s
Aspirin, Adult Low-Dose Aspirin, and Baby Aspirin.
Fluoride Fluoride for prevention of dental car-
ies in children.
Covered for children through age six months -16
years. Covered at $0 copay, prescription (generic
single ingredient only) oral uoride supplementa-
tion products.
Luride, Fluoritab, Sodium Fluoride, Epiur, and
Ethedent.
Folic Acid
& Prenatal
Vitamins
Folic acid for prevention of neural
tube defects.
Covered for patient of childbearing potential who
is planning pregnancy. Covered at $0 copay,
OTC folic acid supplementation products (with
prescription), including prenatal vitamins contain-
ing folic acid for adults. Exclude prescription folic
acid supplementation products and any product
containing > 0.8mg or < 0.4mg of folic acid.
Folic Acid (generic), PrenatalPlus.
Smoking
Cessation
Prescription and OTC (with prescrip-
tion) tobacco smoking cessation
products for adults.
Covered at $0 copay, for those age 18 and older.
Note: Quantity limit of two cycles per year and
max daily dose applies to each active ingredient.
ST required for Nicotrol NS and Inhaler: Trial.
Failure/contraindication to one OTC NRT product
and generic bupriopion.
Nicotrol, Nicotrol NS, Nicotine, Thrive Nicotine,
buproban, Nicotine Gum, Nicoderm CQ, Nicorette,
Commit, bupropion SR, Nicorelief, Stop Smoking
Aid, Nicotine Transdermal System, buproprion
HCL ER, and varenicline.
OTC
Contraceptives
OTC female contraceptive products
and generic OTC Emergency contra-
ceptives (with prescription).
Covered at $0 copay: Female condoms; Spermi-
cides (e.g., vaginal gel/foam/lm/suppositories);
Sponges - Quantity limit of 12 units per month.
Prescription
Contraceptive
Prescription & OTC Emergency
contraceptives (with prescription).
Oral Contraceptives- Monophasic, Biphasic,
Triphasic, Extended Cycle, Four-phasic; Con-
traceptive Patch; Contraceptive Ring; Injectable
Contraceptives.
List is subject to change.
Page 15 June 2024 Prescription Drug Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
Preventive Medications
Drug
Preventive Service
Guidelines Coverage Details
Example
Covered Drugs
Bowel Prep Agents
for Colorectal Cancer
Screening
Select OTC and Rx generic bowel
preparation agents.
Covered at $0 copay, select OTC and Rx generic
bowel preparation agents. Quantity limit of one each
bowel prep dispensing per 365 days.
Colyte.
Breast Cancer – primary
preventive
To prevent the rst occurrence of
breast cancer if a Prior Authoriza-
tion is obtained.
Covered at $0 copay if member is >/35 years of age
and using for primary prevention of breast cancer.
anastrozole, exemestane, raloxifene,
tamoxifen.
Statins Low to moderate dose statins for
the primary prevention of cardio-
vascular disease in adults.
Covered at $0 copay for members 40-75: Lovasta-
tin, for members between ages 40-75, having one
or more cardiovascular risk factors such as dyslipid-
emia, diabetes, hypertension, or smoking, and having
a calculated 10-year risk of a cardiovascular event of
10% or greater, cover atorvastatin (generic Lipitor) 10
& 20 mg and simvastatin (generic Zocor) 5, 10, 20,
40 mg. $0 cost-share requires prior authorization. For
members who do not go through prior authorization,
these medications will continue to be covered at cur-
rent plan cost-share.
lovastatin, simvastatin, atorvastatin.
Preexposure prophylaxis
(PrEP) – prevention of
HIV infection
PrEP for the prevention of HIV in-
fection.
Cover $0 PrEP medications to include generic em-
tricitabine-tenofovir disoproxil fumarate and generic
tenofovir disoproxil fumarate. They are available at $0
cost-share when used for PrEP. Prior Authorization
conrms member is using the medication for PrEP for
the prevention of HIV infection and meets the preven-
tive parameters of the USPSTF recommendation. $0
cost-share requires prior authorization. For members
who do not go through prior authorization, these med-
ications will continue to be covered at current plan
cost-share.
generic emtricitabine-tenofovir diso-
proxil fumarate and generic tenofovir
disoproxil fumarate.
List is subject to change.
Prescription Drug Plans — Member Guidebook June 2024 Page 16
State Health Benets Program School Employees’ Health Benets Program
INFORMATION ABOUT GENERIC DRUGS
What are Generic Drugs?
In many instances, consumers have a choice between
brand name drugs and generic drugs. A brand name
drug is a medication manufactured by a drug compa-
ny that has developed and patented the drug. After the
drug patent expires, other manufacturers who can meet
the FDA production standards may produce and mar-
ket an equivalent product. These medications, known
as generic drugs, are chemically and therapeutically
equivalent to their brand name counterparts.
Substitution of drugs in New Jersey is regulated by law.
The law stipulates that when a provider indicates “sub-
stitution permissible” or gives no indication at all on the
prescription, the pharmacist must substitute a generic
drug, unless otherwise advised by the prescribing pro-
vider that substitution is not permissible.
Who Determines If a Member
Can Receive Generic Drugs?
Your provider determines whether a brand name or
generic product is dispensed to you. You can take full
advantage of the cost savings oered by the Employ-
ee Prescription Drug Plan by asking your provider to
prescribe a generic drug or write a prescription which
allows substitution of a generic drug whenever it is le-
gally permissible.
In general, if your provider writes a prescription that al-
lows only for a brand name drug, the pharmacist will
be required to dispense that drug, and you will be re-
quired to pay the appropriate higher copayment. If you
are interested in taking advantage of the cost savings,
be sure to inform your provider of your preference for a
generic substitute when he or she is prescribing medi-
cations for you and your family.
Note: Certain prescription drugs are subject to step
therapy protocols (see the “Medications under Pre-
ferred Drug Step Therapy (PDST)” chart).
INFORMATION ABOUT COMPOUND DRUGS
Compound Drugs are dened as medications that mix
or alter ingredients to create a medication designed to
the needs of an individual patient. Many ingredients
used in compound medications have not been evalu-
ated for safety and ecacy by the FDA. These ingre-
dients are excluded from coverage through the SHBP/
SEHBP prescription drug plans.
If any of the ingredients in a compound medication are
not covered under the plan, the entire claim will re-
ject. If you are prescribed a compounded medication
that contains excluded ingredients, please ask your
prescriber if there is a commercially available, FDA-
approved medication that is appropriate for you. If your
prescriber believes that the compound is clinically nec-
essary, then the prescriber may initiate a coverage re-
view by contacting OptumRx.
WHAT THE PRESCRIPTION DRUG
PLANS DO NOT COVER
The following services or supplies are not covered un-
der this plan:
• Non-Federal Legend Drugs;
• State-Restricted Drugs;
• Coinsurance or copayments from another pre-
scription plan;
• Coordination of benets with prescription and
medical plans;
• Needles and syringes (except for diabetic use);
• Oral agents for controlling blood sugar that do not
require a prescription;
• Therapeutic devices or appliances including hypo-
dermic needles, syringes, support garments, and
other non-medical supplies;
• Immunizing agents, vaccines, and biological sera;
• Blood, blood products, or blood plasma;
• Drugs dispensed or administered in an outpatient
setting, including but not limited to, outpatient hos-
pital facilities and provider oces;
• Drugs dispensed by or while conned in a hospital,
skilled nursing facility, sanitarium, or similar facili-
ty;
• Infusion drugs and drugs that are administered in-
travenously (IV), except those that are considered
specialty and/or are self-administered subcutane-
ously or intramuscularly;
• Drugs for which the cost is recoverable under any
Workers’ Compensation or Occupational Disease
Law or any State or Governmental Agency, or
medication furnished by another Drug or Medical
Service for which no charge is made to the mem-
ber;
• Drugs prescribed for experimental or investigation-
al indications;
• Drugs dispensed by an unlicensed pharmacy;
• Prescription drugs which lack FDA approval, or
which are approved but prescribed for other than a
FDA-approved use, or in a dosage other than that
approved by the FDA;
• Prescription drugs which do not meet medical ne-
cessity and appropriateness criteria;
• Over-the-counter drugs, or drugs that do not re-
quire a prescription written by a licensed prac-
titioner except for preventive medicines as de-
scribed in the “Preventive Medications” chart;
Page 17 June 2024 Prescription Drug Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
• Professional charges in connection with adminis-
tering, injecting, or dispensing of drugs. Specialty
drugs may be excluded;
• Durable medical equipment, devices, appliances,
and supplies, even if prescribed by a provider;
• Prescription drugs used primarily for cosmetic pur-
poses;
• Prescription drugs for the treatment of erectile dys-
function in excess of the quantity limit of four pills
in any 30-day period; except for one tablet per day
of Cialis 2.5 mg or 5 mg for treatment of benign
prostatic hyperplasia (BPH);
• Prescription drugs to enhance normal functions
such as growth hormones for anti-aging, steroids
to improve athletic performance, or memory en-
hancing drugs, unless medically necessary;
• Cosmetics and health or beauty aids;
• Special foods, food supplements, liquid diet plans,
or any related products;
• Select classes of drugs which have shown no add-
ed benet regarding ecacy or side eects over
lower-cost therapeutic alternatives;
• Herbal, nutritional, and dietary supplements;
• Prescription drugs with a non-prescription (over-
the-counter) chemical and dose equivalent, except
insulin;
• Quantities in excess of dispensing limits; and
• Early rells, i.e., a rell of a prescription drug be-
fore 75 percent of the last ordered and dispensed
supply period has passed.
ENROLLING IN THE
PRESCRIPTION DRUG PLANS
Levels of Coverage
You may enroll under one of the following levels of pre-
scription drug coverage (see the NJDPB website for
denition of partner):
• Single — coverage for yourself only.
• Member/Spouse or Partner — coverage for you
and your spouse or eligible partner only.
• Family — coverage for you, your spouse or eligi-
ble partner, and eligible children.
• Parent and Child(ren) — coverage for you and
your eligible children (but not your spouse, if mar-
ried, or a partner).
When you enroll in a Prescription Drug Plan, you will
be mailed identication cards indicating your level of
coverage.
Employee Coverage
For all eligible employees, coverage for you and your
dependents generally begins on the same date as your
health plan coverage. Please refer to the Summary
Program Description for additional eligibility, enroll-
ment, and coverage information (see the “Health Ben-
ets Publications” section for information on how to ob-
tain this publication).
If you are an employee of a local government or ed-
ucation employer and your employer has resolved to
participate in the Employee Prescription Drug Plans at
a later date than their initial participation in SHBP or
SEHBP coverage, your eective date of prescription
drug coverage for you and your dependents will begin
as of the date your employer commenced participation
in the Employee Prescription Drug Plans.
Transfer of Employment
If you transfer from one SHBP- or SEHBP-participat-
ing employer to another, including transfer within State
employment, coverage may be continued without any
waiting period provided that:
• You are still enrolled in the SHBP or SEHBP when
you begin your new position (COBRA, State part-
time, and part-time faculty coverage excluded);
• You transfer from one participating employer to an-
other; and
• The new employer contacts the Health Benets
Bureau.
Leave of Absence
Leaves of absence encompass all approved leaves
with or without pay. While you are on an approved leave
of absence, you may reduce your level of coverage (for
nancial reasons) for the duration of your leave and in-
crease it again when you return from leave. For exam-
ple, you can reduce Family coverage to either Parent
and Child or Single coverage. Contact your benets ad-
ministrator or human resources representative for more
information concerning coverage while on a leave of
absence.
Note: When a leave of absence is due to suspension,
you are not eligible for benets, with the possible ex-
ception of enrolling for benets under the provisions of
COBRA (see the “COBRA Coverage” section).
When Coverage Ends
Coverage for you and your dependents will end if:
• You voluntarily terminate coverage;
• Your employment terminates;
• Your hours are reduced so you no longer qualify
for coverage;
• You do not make required premium payments;
Prescription Drug Plans — Member Guidebook June 2024 Page 18
State Health Benets Program School Employees’ Health Benets Program
• Your employer ceases to participate in the SHBP
or SEHBP; or
• The SHBP and/or SEHBP are discontinued.
Coverage for your dependents will end if:
• Your coverage ceases for any of the reasons listed
above;
• You die (dependent coverage terminates the rst
day of the pay period following the date of death of
State employees paid through the State’s Central-
ized Payroll Unit, or the rst of the month following
the date of death for all other employees and retir-
ees); or
• Your dependent is no longer eligible for coverage
(divorce of a spouse; dissolution of a civil union or
domestic partnership; children turning age 26 un-
less the dependent child qualies for continuance
of coverage due to disability (see the Summary
Program Description for details).
If your membership in a Prescription Drug Plan ends,
you may be eligible to continue in the Prescription Drug
Plan for a limited period of time under the provisions of
the federal COBRA law (see the “COBRA Coverage”
section).
Certain over age children may be eligible for coverage
until age 31 under the provisions of P.L. 2005, c. 375
(Chapter 375) (see the Summary Program Description
for more information on Chapter 375 coverage).
You cannot convert a Prescription Drug Plan member-
ship to a private plan.
RETIREE COVERAGE
Upon retirement, some members are not automati-
cally covered as a retiree and must submit enrollment
online through Benetsolver, which can be accessed
by navigating to mynjbenetshub or by logging into
myNewJersey. (See the Health Benets Coverage —
Enrolling as a Retiree Fact Sheet for additional infor-
mation).
Generally, your employer will continue to cover you
in the active employee group for one month beyond
your termination of employment. Eligible members
whose employer does not participate in the SHBP or
SEHBP will be enrolled as of their retirement date. (See
the Summary Program Description for additional infor-
mation regarding eligibility and enrollment.)
It is important to note that if you are in the Retired Group,
you and/or your dependent spouse, civil union partner,
eligible same-sex domestic partner, or child who is eli-
gible for Medicare coverage by reason of age or disabil-
ity must be enrolled in both Medicare Part A (Hospital
Insurance) and Part B (Medical Insurance) to enroll or
remain in Retired Group coverage. (See the Summary
Program Description for detailed information).
COBRA COVERAGE
The Consolidated Omnibus Budget Reconciliation Act
of 1985 (COBRA) is a federally regulated law that gives
employees and their eligible dependents the opportuni-
ty to remain in their employer’s group coverage when
they would otherwise lose coverage because of certain
qualifying events. COBRA coverage is available for lim-
ited time periods and the member must pay the full cost
of the coverage plus an administrative fee.
Note: If you are retiring and eligible to enroll in SHBP
or SEHBP Retired Group coverage, the Retired Group
plan will include a prescription drug benet and you
cannot enroll for coverage under COBRA.
Leave taken under the federal and/or State Family
Leave Act is not subtracted from your COBRA eligibility
period.
Under COBRA you may elect to enroll in any or all of
the coverages that you had as an active employee or
dependent (health, prescription drug, dental, and vi-
sion), and may change your health or dental plan when
enrolling in COBRA. You may also elect to cover the
same dependents that were covered while an active
employee, or delete dependents from coverage —
however, you cannot add dependents who were not
covered while an employee except during the annual
Open Enrollment period or unless a qualifying event
(marriage, civil union, birth or adoption of a child, etc.)
occurs within 60 days of the COBRA event. See the
COBRA – The Continuation of Health Benets Fact
Sheet for more information.
Page 19 June 2024 Prescription Drug Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
APPEAL PROCEDURES
Claim Appeal
If you believe an error has been made in processing
your prescription drug claim, you may call OptumRx
Member Services at 1-844-368-8740 (for active em-
ployees and non-Medicare-eligible retirees) or 1-844-
368-8765 (for Medicare-eligible retirees).
Administrative Appeal
An administrative appeal is one for which you believe
benets have been erroneously denied based on the
plan’s limitations and/or exclusions such as whether a
particular drug is covered or a dispensing limit applies
for a certain drug. To le an administrative appeal, you
may call OptumRx Member Services at 1-844-368-
8740 (for active employees and non-Medicare-eligible
retirees) or 1-844-368-8765 (for Medicare-eligible re-
tirees).
Required Information
For either type of appeal, please include the following
information in your letter:
• Names and addresses of patient and employee;
• Your prescription drug plan identication number
(on your prescription drug ID card);
• Your group number and group name as shown on
your prescription drug ID card;
• Employer’s name;
• Payment voucher number and date;
• Claim number, if available;
• Date the prescription was lled;
• Pharmacy’s name;
• Name of the medication;
• Strength of the medication;
• Quantity prescribed;
• Prescription number;
• Amount billed; and
• Amount you paid.
If your drug claim has been denied and you think the
claim should be reconsidered, appeals must be made
within 12 months of the date you were rst notied of
the action being taken to deny your claim. When your
appeal is received, the claim will be researched and
reviewed. OptumRx will notify you in writing of the de-
cision on your appeal within 60 days after the appeal
is received. Special circumstances, such as delays by
you or the provider in submitting necessary informa-
tion, may require an extension of this 60-day period.
The decision on the review will include the specic rea-
son(s) for the decision and refer to specic provisions of
the plan on which the decision is based.
External Review Procedures
After you have exhausted the OptumRx internal appeal
process, if still dissatised, you can request an external
review by an Independent Review Organization (IRO)
as an additional level of appeal.
Generally, to be eligible for an IRO external review, you
must exhaust the two-level internal appeal process, un-
less your claim and appeals were not reviewed in ac-
cordance with all of the legal requirements relating to
pharmacy benet claims and appeals or your appeal is
urgent. In the case of an urgent appeal, you can submit
your appeal in accordance with the identied process
in the “Urgent External Review” section and also re-
quest an external independent review at the same time,
or alternatively you can submit your urgent appeal for
the IRO external review after you have completed the
internal appeal process.
To le for an IRO external review, your request must be
received within four months of the date of the adverse
benet determination (if the date that is four months
from that date is a Saturday, Sunday, or holiday, the
deadline is the next business day). Your request should
be mailed or faxed to:
OptumRx
CA106 - 0286
P.O. Box 25184
Costa Mesa, CA 92626
Fax: 877-239-4565
Non-Urgent External Review
Once you have submitted your external review request,
your claim will be reviewed within ve business days
to determine if it is eligible to be forwarded to an IRO
and you will be notied within one business day of the
decision.
If your request is eligible to be forwarded to an IRO, it
will be randomly assigned to an IRO and your appeal
information will be compiled and sent to the IRO within
ve business days. The IRO will notify you in writing that
it has received the request for an external review and if
the IRO has determined your claim is eligible for review,
the letter will describe your right to submit additional
information within 10 business days for consideration
to the IRO. Any additional information you submit to the
IRO will also be sent to the claims administrator for re-
consideration. The IRO will review your claim within 45
calendar days and send you, the plan, and OptumRx
written notice of its decision. If the IRO has determined
that your claim does not involve medical judgment or
rescission, the IRO will notify you in writing that your
claim is ineligible for a full external review.
Prescription Drug Plans — Member Guidebook June 2024 Page 20
State Health Benets Program School Employees’ Health Benets Program
Urgent External Review
Once you have submitted your urgent external review
request, your claim will be immediately reviewed to de-
termine if you are eligible for an urgent external review.
An urgent situation is one where, in the opinion of your
attending provider, the application of the time periods
for making non-urgent care determinations could seri-
ously jeopardize your life or health or your ability to re-
gain maximum function or would subject you to severe
pain that cannot be adequately managed without the
care or treatment that is the subject of your claim.
If you are eligible for urgent processing, your claim will
be immediately reviewed to determine if your request
is eligible to be forwarded to an IRO, and you will be
notied of the decision. If your request is eligible to be
forwarded to an IRO, your request will be randomly as-
signed to an IRO and your appeal information will be
compiled and sent to the IRO. The IRO will review your
claim within 72 hours and send you, the plan, and Op-
tumRx written notice of its decision.
HIPAA PRIVACY
The Employee Prescription Drug Plan makes every ef-
fort to safeguard the health information of its members
and complies with the privacy provisions of the feder-
al Health Insurance Portability and Accountability Act
(HIPAA) of 1996. HIPAA requires health plans to main-
tain the privacy of any personal information relating to
its members’ physical or mental health. See the “Notice
of Privacy Practices to Members” section.
AUDIT OF DEPENDENT COVERAGE
Periodically, the NJDPB performs an audit using a ran-
dom sample of members to determine if enrolled de-
pendents are eligible under plan provisions. Proof of
dependency such as marriage, civil union, or birth cer-
ticates, or tax returns are required. Coverage for ineli-
gible dependents will be terminated. Failure to respond
to the audit will result in termination of all coverage and
may include nancial restitution for claims paid. Mem-
bers who are found to have intentionally enrolled an
ineligible person for coverage will be prosecuted to the
fullest extent of the law.
HEALTH CARE FRAUD
Health Care fraud is an intentional deception or misrep-
resentation that results in an unauthorized benet to a
member or to some other person. Any individual who
willfully and knowingly engages in an activity intended
to defraud the SHBP or SEHBP will face disciplinary
action that could include termination of employment
and may result in prosecution. Any member who re-
ceives monies fraudulently from a health plan will be
required to fully reimburse the plan.
Page 21 June 2024 Prescription Drug Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
GLOSSARY
This section denes certain important terms that relate
to the SHBP, SEHBP, and the Employee Prescription
Drug Plans.
Copayment/Coinsurance — The amount charged to
the eligible member by a retail pharmacy, the
OptumRx Home Delivery Program, or the Op-
tumRx specialty pharmacy for each prescription
drug order or authorized rell.
Drug Enforcement Agency (DEA) Number — A num-
ber assigned by the DEA to each provider in the
United States who prescribes medications.
Dose Optimization — A drug utilization management
process encouraging safe and appropriate use
of once-per-day medications. Prescriptions
are reviewed for multiple daily drug doses of a
lower-strength medication where a higher-
strength, once daily dose is equally eective.
Dose optimization limits are applied to the
number of pills per day for certain medications,
where the use of multiple pills to achieve a daily
dose is not supported by medical necessity.
Drug Utilization Review (DUR) — DURs are per-
formed by OptumRx to determine a prescrip-
tion’s suitability in light of the patient’s health,
drug history, drug-to-drug interactions, and drug
contraindications.
Federal Legend Drug — A drug that, by law, can be
obtained only by prescription and bears the la-
bel, “Caution: Federal law prohibits dispensing
without a prescription.”
Mail Order Prescription — A prescription which is dis-
pensed by the designated mail order pharmacy,
OptumRx’s Home Delivery Program.
Medical Necessity and Appropriateness — Medi-
cal necessity and appropriateness criteria and
guidelines are established and approved by the
Pharmacy and Therapeutics Committee, which
consists of practicing providers and pharma-
cists. Eligible prescription drugs must meet FDA-
approved indications and be safe and eective
for their intended use. Drugs administered by a
medical professional are not eligible under this
plan. A prescription drug is medically neces-
sary and appropriate if, as recommended by the
treating practitioner and as determined by Op-
tumRx medical director or designee(s) it is all of
the following:
• A health intervention for the purpose of treat-
ing a medical condition;
• The most appropriate intervention, consider-
ing potential benets and harms to the pa-
tient;
• Known to be eective in improving health
outcomes (for new interventions, eective-
ness is determined by scientic evidence.
For existing interventions, eectiveness is
determined rst by scientic evidence; then if
necessary, by professional standards; then, if
necessary, by expert opinion);
• Cost-eective for the applicable condition,
compared to alternative interventions, in-
cluding no intervention. Cost-eective does
not mean lowest price. The fact that an at-
tending practitioner prescribes, orders, rec-
ommends, or approves the intervention, or
length of treatment time, does not make the
intervention medically necessary and appro-
priate.
National Association of Boards of Pharmacy
(NABP) Number — Number assigned by the
NABP to identify the pharmacy. The NABP is an
independent association that assists its member
boards and jurisdictions in developing, imple-
menting, and enforcing uniform standards for the
purpose of protecting the public health.
National Drug Code Number (NDC) — A universal
drug identication number assigned by the FDA.
Non-federal Legend Drug — A drug that does not
require a prescription and is available over-the-
counter.
Non-participating Pharmacy — Any pharmacy that
does not have an agreement with OptumRx.
OptumRx — The pharmaceutical benets manage-
ment company that administers the Employee
Prescription Drug Plans.
Participating Pharmacy — Any pharmacy which has
entered into an agreement with OptumRx.
Participating Pharmacy Allowance — The maximum
amount a retail pharmacy will be reimbursed by
OptumRx for a particular medication. The par-
ticipating pharmacy allowance is specied in the
contract participating pharmacies enter into with
OptumRx.
Pharmacist — A person licensed to practice the pro-
fession of pharmacy and who practices in a
pharmacy.
Prescription Drug Plans — Member Guidebook June 2024 Page 22
State Health Benets Program School Employees’ Health Benets Program
Pharmacy — Any place of business which meets
these conditions: 1) It is registered as a pharma-
cy with the appropriate state licensing agency
and 2) prescription drugs are compounded and
dispensed by a pharmacist. This denition does
not include a provider who dispenses drugs,
pharmacies or drug centers maintained by or
on behalf of an employer, a mutual benet as-
sociation, labor union, trustee or similar person
or group. It also does not include pharmacies
maintained by hospitals, nursing homes, or sim-
ilar institutions.
Prescription — The request for drugs issued by pro-
viders licensed to make the request in the course
their professional practices.
Prior Authorization — A mechanism to screen a drug/
drug class by specic criteria along with a pa-
tient’s medical history to determine if the drug is
covered under the plan. Prior authorization must
be obtained for specic prescription drugs be-
fore they are determined to meet the eligibility
requirements of the plan.
Quantity Management — Limits the maximum amount
of one medication you may receive over a period
of time. Prescription drugs may have a limit for
any of the following reasons:
• Safety;
• Clinical guidelines and prescribing patterns;
• Potential for inappropriate use; and/or
• FDA-approved dosing regimen(s).
Specialty Pharmaceuticals — Oral or injectable
drugs that have unique production, administra-
tion, or distribution requirements. They require
specialized patient education prior to use and
ongoing patient assistance while undergoing
treatment.
Specialty Pharmaceutical Provider — A provider
that dispenses specialty pharmaceuticals.
Step Therapy — Requires prior authorization of cer-
tain more costly prescription drugs, where such
drugs have shown no added benet regarding
ecacy or side eects over lower-cost therapeu-
tic alternatives. Step Therapy may require a trial
of lower-cost prescription drugs before approval
of the higher-cost prescription drug, where clin-
ically appropriate. Step Therapy programs may
be used to monitor the use of new medications
that come on the market (second-line agents) or
select classications of drugs.
Page 23 June 2024 Prescription Drug Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
NOTICE OF PRIVACY PRACTICES TO MEMBERS
This Notice describes how medical information about
you may be used and disclosed and how you can get
access to this information. Please review it carefully.
Protected Health Information (PHI)
The State Health Benets Program and School Em-
ployees’ Health Benets Program (Programs) are re-
quired by the federal Health Insurance Portability and
Accountability Act (HIPAA) and State laws to main-
tain the privacy of any information that is created or
maintained by the programs that relates to your past,
present, or future physical or mental health. This PHI
includes information communicated or maintained in
any form. Examples of PHI are your name, address,
Social Security number, birth date, telephone number,
fax number, dates of health care service, diagnosis
codes, and procedure codes. PHI is collected by the
Programs through various sources, such as enrollment
forms, employers, health care providers, federal and
State agencies, or third-party vendors.
The Programs are required by law to abide by the
terms of this Notice. The Programs reserve the right to
change the terms of this Notice. If material changes are
made to this Notice, a revised Notice will be sent.
Uses and Disclosures of PHI
The Programs are permitted to use and to disclose
PHI in order for our members to obtain payment for
health care services and to conduct the administrative
activities needed to run the Programs without specic
member authorization. Under limited circumstances,
we may be able to provide PHI for the health care oper-
ations of providers and health plans. Specic examples
of the ways in which PHI may be used and disclosed
are provided below. This list is illustrative only and not
every use and disclosure in a category is listed.
• The Programs may disclose PHI to a provider or a
hospital to assist them in providing a member with
treatment.
• The Programs may use and disclose member PHI
so that our Business Associates may pay claims
from doctors, hospitals, and other providers.
• The Programs receive PHI from employers, includ-
ing the member’s name, address, Social Security
number, and birth date. This enrollment informa-
tion is provided to our Business Associates so that
they may provide coverage for health care benets
to eligible members.
• The Programs and/or our Business Associates
may use and disclose PHI to investigate a com-
plaint or process an appeal by a member.
• The Programs may provide PHI to a provider, a
health care facility, or a health plan that is not our
Business Associate that contacts us with ques-
tions regarding the member’s health care cover-
age.
• The Programs may use PHI to bill the member for
the appropriate premiums and reconcile billings
we receive from our Business Associates.
• The Programs may use and disclose PHI for fraud
and abuse detection.
• The Programs may allow use of PHI by our Busi-
ness Associates to identify and contact our mem-
bers for activities relating to improving health or
reducing health care costs, such as information
about disease management programs or about
health-related benets and services or about treat-
ment alternatives that may be of interest to them.
• In the event that a member is involved in a lawsuit
or other judicial proceeding, the Programs may
use and disclose PHI in response to a court or ad-
ministrative order as provided by law.
• The Programs may use or disclose PHI to help
evaluate the performance of our health plans. Any
such disclosure would include restrictions for any
other use of the information other than for the in-
tended purpose.
• The Programs may use PHI in order to conduct an
analysis of our claims data. This information may
be shared with internal departments such as audit-
ing or it may be shared with our Business Associ-
ates, such as our actuaries.
Except as described above, unless a member speci-
cally authorizes us to do so, the Programs will provide
access to PHI only to the member, the member’s au-
thorized representative, and those organizations who
need the information to aid the Programs in the conduct
of their business (our Business Associates). An authori-
zation form may be obtained on our website. A member
may revoke an authorization at any time.
Restricted Uses
• PHI that contains genetic information is prohibited
from use or disclosure by the Programs for under-
writing purposes.
• The use or disclosure of PHI that includes psy-
chotherapy notes requires authorization from the
member.
When using or disclosing PHI, the Programs will make
every reasonable eort to limit the use or disclosure
of that information to the minimum extent necessary to
accomplish the intended purpose. The Programs main-
tain physical, technical, and procedural safeguards that
comply with federal law regarding PHI. In the event of a
breach of unsecured PHI, the member will be notied.
Prescription Drug Plans — Member Guidebook June 2024 Page 24
State Health Benets Program School Employees’ Health Benets Program
Member Rights
Members of the Programs have the following rights re-
garding their PHI:
Right to Inspect and Copy: With limited exceptions,
members have the right to inspect and/or obtain a copy
of their PHI that the Programs maintain in a designated
record set which consists of all documentation relating
to member enrollment and the Programs’ use of this
PHI for claims resolution. The member must make a
request in writing to obtain access to their PHI. The
member may use the contact information found at the
end of this Notice to obtain a form to request access.
Right to Amend: Members have the right to request
that the Programs amend the PHI that we have created
and that is maintained in our designated record set.
We cannot amend demographic information, treatment
records or any other information created by others. If
members would like to amend any of their demographic
information, they should contact their personnel oce.
To amend treatment records, a member must contact
the treating physician, facility, or other provider that cre-
ated and/or maintains these records.
The Programs may deny the member’s request if: 1)
We did not create the information requested on the
amendment; 2) The information is not part of the des-
ignated record set maintained by the Programs; 3) The
member does not have access rights to the information;
or 4) We believe the information is accurate and com-
plete. If we deny the member’s request, we will provide
a written explanation for the denial and the member’s
rights regarding the denial.
Right to an Accounting of Disclosures: Members
have the right to receive an accounting of the instanc-
es in which the Programs or our Business Associates
have disclosed member PHI. The accounting will re-
view disclosures made over the past six years. We will
provide the member with the date on which we made a
disclosure, the name of the person or entity to whom
we disclosed the PHI, a description of the information
we disclosed, the reason for the disclosure, and certain
other information. Certain disclosures are exempted
from this requirement (e.g., those made for treatment,
payment, or health benets operation purposes or
made in accordance with an authorization) and will not
appear on the accounting.
Right to Request Restrictions: The member has the
right to request that the Programs place restrictions on
the use or disclosure of their PHI for treatment, pay-
ment, or health care operations purposes. The Pro-
grams are not required to agree to any restrictions and
in some cases will be prohibited from agreeing to them.
However, if we do agree to a restriction, our agreement
will always be in writing and signed by the Privacy Of-
cer. The member request for restrictions must be in
writing. A form can be obtained by using the contact
information found at the end of this Notice.
Right to Restrict Disclosure: The member has the
right to request that a provider restrict disclosure of PHI
to the Programs or Business Associates if the PHI re-
lates to services or a health care item for which the in-
dividual has paid the provider in full. If payment involves
a exible spending account or health savings account,
the individual cannot restrict disclosure of information
necessary to make the payment but may request that
disclosure not be made to another program or health
plan.
Right to Receive Notication of a Breach: The mem-
ber has the right to receive notication in the event that
the Programs or a Business Associate discover unau-
thorized access or release of PHI through a security
breach.
Right to Request Condential Communications:
The member has the right to request that the Programs
communicate with them in condence about their PHI
by using alternative means or an alternative location
if the disclosure of all or part of that information to an-
other person could endanger them. We will accommo-
date such a request if it is reasonable, if the request
species the alternative means or locations, and if it
continues to permit the Programs to collect premiums
and pay claims under the health plan.
To request changes to condential communications,
the member must make their request in writing, and
must clearly state that the information could endanger
them if it is not communicated in condence as they
requested.
Right to Receive a Paper Copy of the Notice: Mem-
bers are entitled to receive a paper copy of this Notice.
Please contact us using the information at the end of
this Notice.
Questions and Concerns
If you have questions or concerns, please contact the
Programs using the information listed at the end of this
Notice. (Local county, municipal, and board of educa-
tion employees should contact the HIPAA Privacy O-
cer for their employer.)
If members think the Programs may have violated their
privacy rights, or they disagree with a decision made
about access to their PHI, in response to a request
made to amend or restrict the use or disclosure of their
information, or to have the Programs communicate with
them in condence by alternative means or at an al-
ternative location, they must submit their concerns in
writing. To obtain a form for submitting concerns, use
the contact information found at the end of this Notice.
Members also may submit a written concern to the U.S.
Department of Health and Human Services, 200 Inde-
pendence Avenue, S.W., Washington, D.C. 20201.
Page 25 June 2024 Prescription Drug Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
The Program supports member rights to protect the
privacy of PHI. It is your right to le a complaint with
the Program or with the U.S. Department of Health and
Human Services.
Contact Oce:
New Jersey Division of Pensions & Benets
HIPAA Privacy Ocer
Address:
New Jersey Division of Pensions & Benets
Bureau of Policy and Planning
P.O. Box 295
Trenton, NJ 08625-0295
HEALTH BENEFITS CONTACT INFORMATION
Health and Dental plan telephone numbers and mail-
ing addresses are located in the individual plan de-
scriptions located in the “Medical Plan Descriptions”
section and the “Dental Plan Descriptions” section,
respectively.
Addresses
Our mailing address is:
New Jersey Division of Pensions & Benets
P.O. Box 299
Trenton, NJ 08625-0299
Our website address is:
www.nj.gov/treasury/pensions
Our email address is:
pensions.nj@treas.nj.gov
Telephone Numbers
NJDPB:
Oce of Client Services ...........(609) 292-7524
TDD Phone
(Hearing Impaired). . . . . . . . TRS 711 (609) 292-6683
State Employee Advisory
Service (EAS) 24 hours a day ......1-866-EAS-9133
1-866-327-9133
New Jersey State Police Employee
Advisory Program (EAP) .........1-800-FOR-NJSP
Rutgers University
Behavioral Health Care
Employee Advisory Program (EAP). . 1-800-327-3678
New Jersey Department of
Banking and Insurance
Individual Health Coverage
Program Board .................1-800-838-0935
Consumer Assistance for
Health Insurance .........(609) 292-5316 (Press 2)
New Jersey Department of
Human Services
Pharmaceutical Assistance to the
Aged and Disabled (PAAD) ........1-800-792-9745
New Jersey Department of Health
Division of Aging and
Community Services .............1-800-792-8820
Centers for Medicare and
Medicaid Services
Medicare Part A and Part B ...... 1-800-MEDICARE
HEALTH BENEFITS PUBLICATIONS
Publications and fact sheets available from the
NJDPB provide information on a variety of subjects.
Fact sheets, guidebooks, applications, and other pub-
lications are available under the “Publications” drop-
down on our website to view or download.
