On Wednesday, the State Health Benefits Program Plan Design Committee held its regularly scheduled July meeting and adopted seven resolutions for Plan Year 2025.
The first six resolutions are identical to past years. A new provision was added to Resolution 2024-2 Formulary Management and Out of Network Physical Therapy permitting the reexamination and change the formulary at any time to create a new formulary that will save money for the plan, local government employers, and employees.
Resolution 2024-1 Reduced Specialty Copay
Resolution 2024-2 Formulary Management and Out of Network Physical Therapy
Resolution 2024-3 Mail Order Incentive and $0 Copay for Generic Mail Order Prescription Drugs
Resolution 2024-4 Generic Substitution Preference
Resolution 2024-5 Copay Reduction for Retiree Mail Order Preferred Brand Prescription Drugs
Resolution 2024-6 Tiered Network Plan Financial Incentive Pilot Program
Resolution 2024-07, which is new, creates a Centers of Excellence (COE) Pilot Program to attempt to reduce the ever-rising costs of health and prescription drug benefits by bundling pricing, transparent and predictable pricing, ensuring the demonstration of superior clinical outcomes versus national averages and versus the Third-Party Administrator (TPA’s) in-network providers. The pilot applies to the PPO plans and lasts five years. The non-emergent procedures subject to the pilot program include:
- Bariatric surgery. Examples include but are not limited to procedures such as gastric bypass surgery, gastric banding, duodenal switch and sleeve gastrectomy.
- Knee replacement surgery. Examples include but are not limited to procedures such as total knee arthroplasty, partial knee arthroplasty and patellofemoral arthroplasty.
- Hip replacement surgery. Examples include but are not limited to procedures such as total hip arthroplasty, partial hip arthroplasty and hip resurfacing.
- Spine surgery. Examples include but are not limited to procedures such as discectomy, laminectomy, and spinal fusion.
- Heart surgery. Examples include but are not limited to procedures such as coronary artery bypass and heart valve surgery.
Members are incentivized to utilize the COE by having no co-payments. During the first two years of the pilot program, the COE shall provide an incentive in the form of a $150 gift card.
If a member has a procedure subject to the pilot program with a provider in the TPA’s network, instead of the COE, there are escalating cost-sharing that increase by year:
- Year 1 copayment equal to the plan’s emergency room copayment
- Year 2 $400 copayment
- Year 3 $600 copayment
- Year 4 $800 copayment
- Year 5 $1,000 copayment
The July 29 meeting of the State Health Benefits Commission has been canceled. It will be rescheduled prior to enrollment opening for Plan Year 2025.
Contact: Paul Penna, Senior Legislative Analyst, ppenna@njlm.org, 609-695-3481, x110.