Important State Health Benefit Update from Kevin Lyons

On July 6th, the State Health Benefits Plan Design Committee approved a series of plans that will significantly change the way that health benefits are delivered to our members.

In an effort to contain costs and provide a higher standard of care, the Design Committee passed the following modifications to the State Health Benefits Plan for the plan year 2016. The modifications on the Hepatitis C medications and the changes in compounded medicines will take place within 90 days of notification of the members of the State health Benefits Plan who are affected.

The State Health Benefits Plan will initiate a pilot program that involves Direct Primary Care Medical Homes. The nature of this pilot will allow you to go to a primary care physician who will manage your health care needs for no copay and hopefully detect chronic diseases that ultimately drive the cost of care downstream. There is a detailed description of the pilot in the July issue of COPS. While the public safety representatives abstained on the motion for this model, it was not because they did not support the concept. There was a genuine movement to create competition to drive down costs.

Compounded drugs will only be issued on a basis of medical necessity. This is due to an abuse of the plan that allows compound pharmacies to solicit patient and charge thousands of dollars for compounds that only cost pennies.

Hepatitis C medications that cost hundreds of thousands of dollars will be issued on a step therapy basis that will begin with Viekera Pack, and if that is unsuccessful, will move to the other drugs developed for this purpose. The reason for this is that Express Scripts negotiated a lower rate for those drugs.

Horizon will be offering a new plan that will replace the HMO 1525, 2030 and 2035 plans for active members only. This Tiered network will offer reduced copays for in network, but a higher deductible out of network. A detailed description will be disseminated to your delegates in the coming days. This plan will be between 20-25% less than the Direct and freedom plans.

There will be a new fee structure for in network payments to practitioners in the fields of chiropractic care and acupuncture. The out of network benefits will be reduced in order to encourage them back into the network.

Emergency room copays will be increased by $25 for each plan under $100. These are waived for pediatric and physician referrals. The copay will stay at that level if Emergency room utilization is decreased by 35% in 2016.

Finally there will be a wellness initiative at Rutgers University to study the benefits of such a plan. This will be cone in cooperation with Robert Wood Johnson hospital.

The committee designed these changes to attempt to reduce premium costs going forward and will continue to strive to improve the health of our members.

The Design Committee is truly working as a team to develop plans that will benefit our members and the PBA appreciates everyone on the committee for their hard work, both labor and management.