We have just received information that the Division of Banking and Insurance has denied a request from Horizon to utilize American Specialty Health Network to administer Chiropractic, Physical Therapy, Occupational Therapy, Acupuncture and Speech Therapy for all Horizon customers both in and out of the State Health Benefits Plan.

The New Jersey State PBA led the initiative to disallow the implementation for three main reasons. First, the belief that the model that would be implemented would restrict access to much needed, non surgical options. Next, to help limit use of opiates for musculoskeletal injuries, which are suffered by our members on a regular basis. The last reason was because of the practices that were outlined in a 2012 consent order involving the network.

This denial does not mean that Horizon cannot make future application for these services and we ask our members to remain vigilant and responsive in our continued effort to protect our health benefits.

Last Friday, May 11, 2018 a NJ Court of Appeals invalidated the contract awarded to OptimRx as the Pharmacy Benefit Manager (PBM) for the New Jersey State Health Benefit Plan as well as the SEHBP. This was done as a result of a suit filed by Express Scripts International, the former PBM for the SHBP/SEHBP. The court ruled that the submissions by OptimRx were not acceptable (see article below).

I spoke to the Division today who has assured me that there will be no changes until at least 1/1/2019. That is to say that your prescription plan, if enrolled in the State Health Benefits Plan, will remain status quo with no interruptions in service.

As the matter develops, we will keep you informed through all of our communication outlets. article

Appellate Court Decision

Unfortunately and once again, uninformed and consistently incorrect self-appointed experts are spreading misinformation regarding a recent vote made by Kevin Lyons, our representative on the State Health Benefits Plan Design Committee.

Kevin’s vote was responsible, logical, and consistent with the direction he and the State PBA has been working towards, which is to lower the cost of our members’ contributions while avoiding any negative impact on the level of benefits they currently receive. Without this vote, a PFRS member in Direct 10 would see his or her contribution increase an additional $695.00 per year and a total contribution of $12,290.00.

Both Active and Retired members in the Police and Fire community will benefit from the results of his vote.  This is a victory for all of our members and was authorized by me after months of research and discussion.

The State PBA spends untold hours and funds on training, preparing and lobbying for positive change for our members regarding pension and benefits.  Other sources of information have been consistently incorrect in their assessment of issues and all of their actions have failed to bring about any change that they have predicted or sought.

Please take this information and contact your Union representatives with any questions.  We are in Unions to do better collectively than we can as individuals.  Let’s support the effort and get better results and send the out-of-state and out-of-touch keyboard commentators packing.

Pat Colligan, State President

From Kevin Lyons:

On August 29, 2016, the State Health Benefits Design Committee adopted plan changes to be implemented in the coming months.  As we have said all along, we would not endorse any changes that would shift more costs on to our members.  After 5 months of negotiations with the state representatives, we were able to produce a package that would change some of the processes that would create a rate reduction for local actives and an approximate 3.5% increase for state actives.  If action were not taken, our members would have been facing 6% and 9% rate increases respectively.  Currently local actives pay 9.4% more than State actives, and shifting costs from one plan to another is not allowable.

Below are the seven changes that were acted upon and a very brief description of each explaining the reason that the PBA chose to support the resolution.  It is important to remember that these changes only apply to those in the State Health Benefits Plan.

  1. We voted on a resolution that would ensure equal benefits and create prescription drug savings for all post-65 retirees who are being switched to a Medicare Advantage Plan as a contract change already implemented by the State Health Benefits Commission.  If a level of savings is reached of 20% the member will save on lowered copays.  The plans are actually stronger and the network is larger.  This will have a positive effect on the Chapter 330 rates as well, decreasing costs for those retirees.  There will be no immediate impact on current prescription copays.
  2. Mandatory use of generic drugs in certain situations:  The SHBP generic utilization rate is at approximately 75% instead of at the 85% it should be.  This will require that a generic be dispensed first (providing lower copays for our members) and if the member can demonstrate a medical necessity, they will receive the name brand.
  3. Formulary management:  With the skyrocketing cost of prescription drugs, the Pharmacy Benefit Manager has created a list of drugs that they have chosen to discontinue unless the drug is proven to be medically necessary.

    Both prescription drug changes are good for one year and will be discontinued without an affirmative vote of the committee.  This will not apply to Medicare retirees.
  4. Prescription Drug Step therapy:  Our members have had this for years, there are no changes for any of our members.
  5. Restructure Physical Therapy out-of-network payments:  Some physical therapists were taking advantage of the payment structure.  After extensive research it was determined that there were over 1,400 physical therapists in New Jersey and the only State employees that lived outside of a few miles to a provider were those that lived far out of state.
  6. Support to extend the pharmacy benefit manager contract and add an auditor for 100% of the claims.  We project that this will save us millions in the future until we can implement a reverse auction.
  7. Incentives for switching to the tiered network:  Any State employee that switches to the tiered network for two years will receive $1,000 for single coverage, $1,250 for member and spouse and member and child, and $2,000 for family.

Another of the benefits that came out of the passage of the resolution is the release of transitional aid that will help our brothers and sisters, mostly PBA members, in distressed cities keep working.  So this was a win for our members all the way around.

We did not take the approval of this package lightly and the labor side of the commission got almost everything they asked for in the package while keeping rates and benefits in check with ironclad safeguards.  We will not risk the wellbeing of our members to pacify the agendas of other organizations.  Our members pay more both in premium share and premium, we are different and will continue to look out for the best interests of all of our members, both active and retired.

Today, President Colligan attended a joint meeting of the labor members of the State Health Benefits Design Committee and the State Education Health Benefits Design Committee along with Senate President Steven Sweeney to discuss a new concept in health care delivery for SHBP members.

At the meeting, a concept in health care delivery, direct primary care medical homes, was discussed. In this model, members would be able to utilize a cadre of doctors and would be centered around the whole health of the patient.

The SHBPDC labor side agreed to endorse a concept and attempt to develop a plan contingent on agreement of the labor and management side. It is important to know that the committee has not agreed to any specifics and a majority of the committee is required to design any plan.

At a subsequent press conference, President Colligan stood shoulder to shoulder with the members of the design committees and other public sector leaders to introduce the concept. We will keep you informed and will have a full description of the optional pilot concept in the near future