New Jersey Administrative Code
Title 17 - TREASURY - GENERAL
Chapter 9 - STATE HEALTH BENEFITS PROGRAM
Subchapter 6 - RETIREMENT
Section 17:9-6.10 - Retiree prescription drug plan
Current through Register Vol. 56, No. 6, March 18, 2024
(a) The following terms, as used in this section, shall have the following meanings:
"Brand name" means the proprietary or trade name assigned to a drug product by the manufacturer or distributor of the drug product.
"Generic drug products" means prescription drug products and insulin approved and designated by the U.S. Food and Drug Administration as therapeutic equivalents for reference listed drug products. It includes drug products listed in the New Jersey Generic Formulary by the Drug Utilization Review Council pursuant to 24:6E-1 et seq.
"Mail-order pharmacy" means the mail order program available through the provider.
"Other brands" means prescription drug products that are not preferred brands or generic drug products. A new drug product approved by the U.S. Food and Drug Administration, which is not a generic drug product shall be included in this category until the provider makes a determination concerning inclusion of the drug product in the list of preferred brands.
"Preferred brands" means brand name prescription drug products and insulin determined by the provider, to be more cost-effective alternatives for prescription drug products and insulin with comparable therapeutic efficacy within a therapeutic class, as defined or recognized in the United States Pharmacopeia or the American Hospital Formulary Service Drug Information, or by the American Society of Health Systems Pharmacists. A drug product for which there is no other therapeutically equivalent drug product shall be a preferred brand. Determinations of preferred brands by the provider shall be subject to review and modification by the State Health Benefits Program Plan Design Committee.
"Prescription drug plan" means the plan or plans for providing payment for eligible prescription drug expenses for all State Health Benefit Program retirees and their eligible dependents who participate in the PPO, HMO, high deductible health plans, or other SHBP health plans offered to subscribers, as prescribed by this section.
"Provider" means an insurance company, hospital, medical, or health service corporation, pharmacy benefit manager, or health maintenance organization under agreement or contract with the Commission to administer the prescription drug plan.
"Retail pharmacy" means a pharmacy, drug store or other retail establishment in this State at which prescription drugs are dispensed by a registered pharmacist under the laws of this State, or a pharmacy, drug store or other retail establishment in another state at which prescription drug products are dispensed by a registered pharmacist under the laws of that state if expenses for prescription drug products dispensed at the pharmacy, drug store or other retail establishment are eligible for payment under the prescription drug plan.
"Other brands" means prescription drug products which are not preferred brands or generic drug products. A new drug product approved by the U.S. Food and Drug Administration which is not a generic drug product shall be included in this category until the provider makes a determination concerning inclusion of the drug product in the list of preferred brands.
(b) Reimbursement for the co-payments required under the prescription drug plan shall not be made under the medical portion of any SHBP plan.
(c) Eligibility of prescription drug expenses for coverage under the prescription drug plan shall be determined on the same basis as reasonable and necessary medical expenses under the State Health Benefits Program.
(d) A co-payment shall be required for each prescription drug expense until a retired member or eligible dependent satisfies the maximum annual out-of-pocket expense for a calendar year. Co-payment amounts in effect for the current year for generics, preferred brands, and other brands, as well as maximum annual out-of-pocket expenses, are provided on the Division of Pensions and Benefits website.
(e) The supply of a drug product eligible for coverage under the prescription drug plan for each prescription drug expense shall be limited to 30 days if the prescription is filled at a retail pharmacy, and 90 days if the prescription is filled through the mail-order pharmacy.
(f) Notice of increases in the amounts of the co-payments and the maximum out-of-pocket expense shall be published in the New Jersey Register and posted to the Division's website annually.
(g) The provider administering the prescription drug plan shall comply with N.J.A.C. 11:22-5 in the administration of the prescription drug plan:
