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«STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY DIVISION OF PENSIONS AND BENEFITS Horizon HMO MEMBER HANDBOOK FOR EMPLOYEES AND RETIREES ENROLLED IN ...»

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OR The final adverse benefit determination (decision upon appeal) involving medical judgment concerns a medical condition such that the completion of a Standard External Appeal would seriously jeopardize the life or health of the member or would jeopardize the member’s ability to regain maximum function, or if final adverse benefit determination involving medical judgment concerns an admission, availability of care, continued stay or a health care item or service for which the member received emergency services, but has not been discharged from the facility.

In instances of an expedited request, your request can be made by calling a Horizon BCBSNJ Appeals Coordinator at 1-888-221-6392. For Expedited External Review requests, the final notice of the decision must be provided as expeditiously as the member’s medical condition or circumstances require, but in no event shall exceed 72 hours from the IRO’s receipt of the request for Expedited External Review.

SHBP/SEHBP ADMINISTRATIVE APPEAL PROCEDURE

The member or the member’s authorized representative may appeal and request that Horizon HMO reconsider any claim or any portion(s) of a claim for which they believe benefits have been erroneously denied based on Plan limitations and/or exclusions. This appeal may be on an administrative nature. Administrative appeals question plan benefit decisions such as whether a particular service is covered or paid appropriately. Examples

of Administrative Appeals include:

• Visits beyond the 20-visit chiropractic limit

• Benefits beyond the reasonable and customary allowance

• Routine Vision Services rendered out-of-network

• Benefits for a wig that exceed the $500/24 month limit

• Hearing Aid for a 60 year old member

NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —

Adverse benefit determinations involving the application of plan benefits may usually be

appealed up to three (3) times as outlined below:

• First Level Administrative Appeal – The First Level Administrative Appeal of an adverse benefit determination.

• Second Level Administrative Appeal – The Second Level Administrative Appeal of an adverse benefit determination available to you after completing a First Level Administrative Appeal.

• Commission Appeal – The Third Level Administrative Appeal of an adverse benefit determination, which, at your request, would generally follow a Second Level Administrative Appeal. A Commission Appeal provides you the right to appeal to the State Health Benefits Commission/School Employees’ Health Benefits Commission.

An overview of the administrative appeal process is provided below. An SHBP/SEHBP Administrative Appeals Procedure brochure will be provided with every administrative adverse benefit determination. The brochure provides a comprehensive description of the procedures.

First Level Administrative Appeal The member may request an administrative appeal by calling 1-800-414-SHBP (7427) or

submitting a written appeal to:

–  –  –

The member has one (1) year following your receipt of the initial adverse benefit determination letter to request an Administrative Appeal.

The First Level Administrative Appeal should include the following information:

• Name and address of the patient and the member;

• Member’s identification number;

• Date(s) of service(s);

• Provider’s name and identification number;

• Physician’s name and identification number;

• The reason you think the claim/service should be reconsidered;

• All documentation supporting your appeal.

You will receive a written response to your First Level Administrative Appeal within 30 days. If you are not satisfied with this written determination, a Second Level Administrative Appeal may be requested.

66 — HORIZON HMO MEMBER HANDBOOK Second Level Administrative Appeal The member may request a Second Level Administrative Appeal within one (1) year following receipt of the initial adverse benefit determination letter by calling 1-800-414-SHBP (7427), or by writing to the address noted earlier. The member may also send an appeal via fax to 1-973-274-4599.

During the Second Level Administrative Appeal, Horizon HMO will review any additional evidence the member wished to supply in support of the appeal. The member will receive a written determination of the final decision within 30 days. This will complete the Horizon HMO appeal options.

Commission Appeal Once all appeal options have been exhausted through Horizon HMO the member may appeal to the State Health Benefits Commission/School Employees’ Health Benefits Commission (Commission). If dissatisfied with a final Horizon HMO decision on an administrative appeal, you have one (1) year following receipt of the initial adverse benefit determination letter to request a Commission Appeal. Only the member or the member’s legal representative may appeal, in writing, to the Commission. If the member is deceased or incapacitated, the individual legally entrusted with his or her affairs may act on the member’s behalf.

Request for consideration must contain the reason for the disagreement along with





copies of all relevant correspondence and should be directed to:

Appeals Coordinator State Health Benefits Commission/ School Employees’ Health Benefits Commission P.O. Box 299 Trenton, NJ 08625-0299 The member will be advised by the Commission how to arrange a hearing date, the date of the hearing and the option to attend and appear before the Commission.

Notification of all Commission decisions will be made in writing to the member. If the Commission denies the member’s appeal, the member will be informed of further steps he or she may take in the denial letter from the Commission. Any member who disagrees with the Commission’s decision may request in writing to the Commission, within 45 days, that the case be forwarded to the Office of Administrative Law. The Commission will then determine if a factual hearing is necessary. If so, the case will be forwarded to the Office of Administrative Law. An Administrative Law Judge (ALJ) will hear the case and make a recommendation to the Commission, which the Commission may adopt, modify or reject.

If your case is forwarded to the Office of Administrative Law, you will be responsible for the presentation of your case and for submitting all evidence. The member will be responsible for any expenses involved in gathering evidence or material that will support the grounds for appeal. The member will be responsible for any court filing fees or related costs that may be necessary during the appeal process. If an attorney or expert medical

NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —

testimony is required, the member will be responsible for any fees or costs incurred.

If the recommendation is rejected, the administrative appeal process is ended. When the administrative process is ended, further appeals may be made to the Superior Court of New Jersey, Appellate Division.

PRESCRIPTION DRUG BENEFITS

The State Health Benefits Commission and School Employees’ Health Benefits Commission require that all covered employees and retirees have access to prescription drug coverage.

The Commissions reserve the right to establish dispensing limits on any medication based on Food and Drug Administration (FDA) recommendations and medical appropriateness. Prior Authorization, Drug Utilization Review, Dose Optimization, Step Therapy, Preferred Drug Step Therapy (PDST)* and the Specialty Pharmacy Program are employed to ensure that the medications that are reimbursed under the plan are the most clinically appropriate and cost effective. Volume restrictions also apply to certain drugs such as sexual dysfunction drugs (Viagra, etc.). Certain drugs that require administration in a physician’s office may be covered through your medical plan.

*PDST does not apply to certain State employees and their dependents.

EMPLOYEE PRESCRIPTION DRUG COVERAGE

State Employees State employees enrolled in Horizon HMO medical plans have access to the SHBP/SEHBP Employee Prescription Drug Plans. Plan benefits are available through retail pharmacies, by mail order through Express Scripts, and from specialty pharmacy services provided through Accredo, Express Scripts’ specialty pharmacy.

The plans feature a three-tier copayment design, except for high deductible health plans.

Retail pharmacy services require a copayment for up to a 30-day supply of prescription drugs. Mail order participants can receive up to a 90-day supply of prescription drugs for one mail order copayment. Specialty pharmacy services are only provided via mail through Accredo. If your doctor prescribes a specialty pharmaceutical, you will not be able to fill the prescription at a retail pharmacy.

See the SHBP/SEHBP Prescription Drug Plans Member Handbook for additional information on prescription drug benefits and limitations.

The amount that State employees and their eligible dependents pay for prescription drugs is determined by the medical plan the employee selects. *HMO1525, 2030, 2035 plans are not available to active employees.

Note: In the past, regardless of which medical plan you were enrolled, the Employee Prescription Drug Plan copayments were the same. As a result of the SHBP/SEHBP Plan Design Committees’ actions, the copayments for prescription drugs are now determined by the medical plan you select.

–  –  –

Note: The following preventive medications are covered with a doctor’s prescription with a zerodollar copayment for certain members meeting specific criteria (see the Prescription Drug Plans Member Handbook for specific limits related to age, gender, and medical condition): Aspirin, Fluoride, Folic Acid, Iron supplements, and certain drugs that assist with Smoking Cessation.

NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —

LOCAL GOVERNMENT AND LOCAL EDUCATION

EMPLOYEES The amount that local government/education employees and their eligible dependents pay for prescription drugs is determined by the prescription drug plan option provided by the employer and the medical plan the employee selects. Local government and local education employers may elect one of the following three options to provide prescription drug benefits to their employees: The SHBP/SEHBP Employee Prescription Drug Plans, HMO Prescription Drug Plan, or a private (non-SHBP/SEHBP) prescription drug plan.

1. The SHBP/SEHBP Employee Prescription Drug Plans: Benefits are available through retail pharmacies, by mail order through Express Scripts, and from specialty pharmacy services provided through Accredo, Express Scripts’ specialty pharmacy.

The plans feature a three-tier copayment design. Retail pharmacy services require a copayment for up to a 30-day supply of prescription drugs. Mail order participants can receive up to a 90-day supply of prescription drugs for one mail order copayment.

Specialty pharmacy services are only provided via mail through Accredo. If your doctor has prescribed a specialty pharmaceutical, you will not be able to fill the prescription at a retail pharmacy.

See the SHBP/SEHBP Prescription Drug Plans Member Handbook for additional information on prescription drug benefits and limitations.

The State Health Benefit and School Employees’ Health Benefit Plan Design Committees establish the copayment amounts on an annual basis.

Note: In the past, regardless of which medical plan you were enrolled, the Employee Prescription Drug Plan copayments were the same. As a result of the SHBP/SEHBP Plan Design Committees’ actions, the copayments for prescription drugs are now determined by the medical plan you select.

In Plan Year 2016 a local government/education employee or dependent will pay the following copayment amounts.

Note: HMO1525, HMO2030, and HMO2035 plans are available ONLY to ACTIVE LOCAL EDUCATION Employees.

–  –  –

* Horizon HMO1525, Horizon HMO2030, and Horizon HMO2035 are not available to Local Government Employees.

**You Pay The Applicable Generic Copayment As Listed Above, Plus The Cost Difference Between The Brand Drug And The Generic Drug.

NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —

Note: The following preventive medications are covered with a doctor’s prescription with a zero-dollar copayment for certain members meeting specific criteria (see the Prescription Drug Plans Member Handbook for specific limits related to age, gender, and medical condition): Aspirin, Fluoride, Folic Acid, Iron supplements, and certain drugs that assist with Smoking Cessation.

2. The HMO Prescription Drug Plan: Available to employees enrolled in Horizon HMO, Horizon HMO1525, Horizon HMO2030, or Horizon HMO2035 when the local public employer does not provide either the Employee Prescription Drug Plans or a private prescription drug plan. Plan benefits are available through participating retail

pharmacies, by mail order through Express Scripts, or online at:

www.express-scripts.com/statenj and from specialty pharmacy services provided through Accredo, Express Scripts’ specialty pharmacy.

The HMO Prescription Drug Plan features a three-tier copayment design for prescription drugs that are prescribed by your Primary Care Physician (PCP) or a provider to whom your PCP has referred you.

See the SHBP/SEHBP Prescription Drug Plans Member Handbook for additional information on prescription drug benefits and limitations.

In Plan Year 2016 a local government/education employee or dependent will pay the following copayment amounts.

–  –  –

* Horizon HMO1525, Horizon HMO2030, and Horizon HMO2035 are not available to Local Government Employees.

**You pay the applicable generic copayment as listed above, plus the cost difference between the brand drug and the generic drug.

–  –  –



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