Prescription Drug Plans - State

1 Prescription drug Plans Member GuidebookPensions & BenefitsHP-0506-0118 For the State Health Benefits Program and the School Employees Health Benefits Program Prescription drug Plans Member guidebook February 2018 Page 2 State Health benefits Program school employees Health benefits Program Table OF COnTenTsIntroduction ..3eligibility ..3 plan benefits ..3 Retail Pharmacy ..3 Mail Order Service ..3 Specialty Pharmaceutical Provider ..3 Copayment/Coinsurance amounts ..4 State Employees ..4 Local Government Employees ..4 Local Education Employees ..7 Retiree Prescription drug Coverage ..9 Medicare Part D ..9 State Retirees and Local Government Retirees ..10 Local Education Retirees ..10 Purchasing Prescription Drugs at a Pharmacy.

2 11 Participating Pharmacies ..11 Non-Participating Pharmacies ..11 How to File a Claim for Reimbursement ..11 Compound Claim Processing ..12 Mail Order services ..12 How the Mail Order Service Works ..12 Transfer an Existing Prescription ..12 Online Access ..12 Obtaining Refills Through the Mail Order Service ..12 Coverage and services Provided by the employee Prescription drug plan ..13 Dispensing Limits ..13 Utilization Management ..13 Preventative Medications ..15 Medications Under Preferred drug Step Therapy (PDST) ..16 Information about Generic Drugs ..17 What are Generic Drugs? ..17 Who Determines if a Participant can Receive Generic Drugs? ..17 Information about Compound Drugs ..17 What the employee Prescription drug Plans DO nOT Cover.

3 17enrolling in the employee Prescription drug Plans ..18 Levels of Coverage ..18employee Coverage ..18 Transfer of Employment ..18 Leave of Absence ..18 When Coverage Ends ..18 Retiree Coverage ..19 CObRa Coverage ..19appendix I ..20 Appeal Procedures ..20 Claim Appeal ..20 Administrative Appeal ..20 Required Information ..20 External Review Process ..20 Urgent External Review ..20 HIPAA Privacy ..21 Audit of Dependent Coverage ..21 Health Care Fraud ..21appendix II ..22 Glossary ..22appendix III ..24 Notice of Privacy Practices ..24 Protected Health Information ..24 Uses and Disclosures of PHI ..24 Restricted Uses ..24 Member Rights ..25 Questions and Complaints ..25appendix IV ..27 Health Benefits Contact Information.

4 27 Addresses ..27 Telephone Numbers ..27 Health Benefit Publications ..28 General Publications ..28 Health Benefits Fact Sheets ..28 Health Benefits Member Guidebooks ..28 Page 3 February 2018 Prescription drug Plans Member Guidebookschool employees Health benefits Program State Health benefits ProgramInTRODUCTIOnThe State Health benefits Program (sHbP) was es-tablished in 1961 . It offers medical, Prescription drug , and dental coverage to qualified 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 Benefits Commission (SHBC) is the executive organization responsible for overseeing the S H B P.

5 The State Health Benefits Program Act is found in the New Jersey Statutes Annotated, Title 52, Article 14-17 .25 et seq . Rules governing the operation and ad-ministration of the program are found in Title 17, Chap-ter 9 of the New Jersey Administrative Code .The school employees Health benefits Program (seHbP) was established in 2007 . It offers medical, Prescription drug , and dental coverage to qualified 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 Benefits Commission (SEHBC) is the executive organization responsible for overseeing the SEHBP . The School Employees Health Benefits Program Act is found in the New Jersey Statutes Annotated, Title 52, Article 14-17.

6 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 & benefits (nJDPb), specifically the Health Benefits Bureau and the Bureau of Policy and Planning, are responsible for the daily administrative activities of the SHBP and the S E H B P . The Prescription drug Plans are administered for the SHBP and SEHBP by OptumRx, the pharmacy benefit 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 identification card is provided and use of the ID card is required to obtain medications at a participating retail pharmacy for the designated co-payment.

7 Every effort has been made to ensure the accuracy of the Prescription drug Plans Member guidebook . However, State law and the New Jersey Administra-tive Code govern the SHBP and SEHBP . If there are discrepancies between the information presented in this booklet and/or plan documents and the law, regu-lations, 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 booklet, you have any questions, comments, or suggestions regarding the information presented, please write to the New Jersey Division of Pensions & Benefits, P.

8 O . Box 295, Trenton, NJ 08625-0295, call us at (609) 292-7524, or send an email to: drug PlanseligibilityThe Prescription drug Plans rules of eligibility and information on maintaining coverage are the same as those for the State Health Benefits Program (SHBP) and School Employees Health Benefits Program (SE-HBP) medical Plans . Please refer to the Summary Pro-gram Description for additional eligibility, enrollment, and coverage information (see page 28 for information on how to obtain this publication) . The only exception is employees of local employers who have chosen a pri-vate Prescription drug plan for their employees rather than one of the SHBP/SEHBP Prescription drug Plans . If your local employer has chosen a private prescrip-tion drug plan , it must be substantially similar to the Prescription drug Plans offered by the SHBP/SEHBP.

9 Note: The copayments for Prescription drugs are de-termined by the medical plan you select . plan benefitsThe Prescription drug Plans are administered for the SHBP and SEHBP by OptumRx and can be obtained through a participating pharmacy, through the Op-tumRx mail order, or through BriovaRx, OptumRx s specialty pharmacy service . A Prescription drug plan identification card is provided and use of the ID card is required to obtain medications at a participating retail pharmacy for the designated copayment/coinsurance .Retail PharmacyNormally, 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.

10 Additional information about purchasing Prescription drugs at a retail pharmacy begins on page 11 .Mail Order serviceMail order benefits are available where participants can receive up to a 90-day supply of Prescription drugs for one copayment . Additional information about using the mail order service begins on page 12 . specialty Pharmaceutical ProviderSpecialty pharmaceuticals are provided through Brio-vaRx (OptumRx s specialty pharmacy), which is the exclusive provider for specialty pharmaceuticals for the Employee Prescription drug Plans . Prescription drug Plans Member guidebook February 2018 Page 4 State Health benefits Program school employees Health benefits Program If your doctor has prescribed a specialty pharmaceuti-cal, you will not be able to fill the Prescription at a re-tail pharmacy.