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. 14, July 15, 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:
1. The provider shall follow the standards
				and procedures required to obtain approval for its prescription drug plan
				offerings and utilize selective contracting arrangements that promote health
				care cost containment while adequately preserving quality of care, pursuant to
11:4-37.1
and
37.2
.
2. The
				provider shall follow the standards established for selective contracting
				arrangements, pursuant to
11:4-37.3
.
3. The provider shall
				follow selective contracting arrangement approval and amendment procedures,
				pursuant to
11:4-37.4
.