Division of Pensions and Benefits

Governor Chris Christie • Lt.Governor Kim Guadagno

The Official Web Site For The State of New Jersey - Department of Treasury

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STATE HEALTH BENEFITS PROGRAM and
SCHOOL EMPLOYEES' HEALTH BENEFITS PROGRAM
EMPLOYEE PRESCRIPTION DRUG PLAN COPAYMENTS

State Employees | Local Government Employees | Local Education Employees

STATE EMPLOYEES ENROLLED IN THE SHBP

Employee Prescription Drug Plan copayments for Plan Year 2013

Copayments are based on the medical plan in which the employee is enrolled

Aetna Freedom15, NJ DIRECT15, Aetna HMO, Horizon HMO | 1525 Plans | 2030 Plans | High Deductible Health Plans

Aetna Freedom15, NJ DIRECT15, Aetna HMO, Horizon HMO

RETAIL PHARMACY COPAYMENT AMOUNTS Up to a 90-day Supply
Supply	Generic	Brand Name Drug without generic equivalents	Brand Name Drug with generic equivalents
01-30 days	$3	$10	$25
31-60 days	$6	$20	$50
61-90 days	$9	$30	$75

MAIL ORDER COPAYMENT AMOUNTS Up to a 90-day Supply
Supply	Generic	Brand Name Drug without generic equivalents	Brand Name Drug with generic equivalents
01-90 days	$5	$15	$40

Aetna Freedom 1525, NJ DIRECT1525, Aetna HMO1525, Horizon HMO1525

RETAIL PHARMACY COPAYMENT AMOUNTS Up to a 90-day Supply
Supply	Generic	Brand Name Drug without generic equivalents	Brand Name Drug with generic equivalents
01-30 days	$7	$16	$35
31-60 days	$14	$32	$70
61-90 days	$21	$48	$105

MAIL ORDER COPAYMENT AMOUNTS Up to a 90-day Supply
Supply	Generic	Brand Name Drug without generic equivalents	Brand Name Drug with generic equivalents
01-90 days	$18	$40	$88

Aetna Freedom2030, NJ DIRECT2030, Aetna HMO2030, Horizon HMO2030

RETAIL PHARMACY COPAYMENT AMOUNTS Up to a 90-day Supply
Supply	Generic	Brand Name Drug without generic equivalents	Brand Name Drug with generic equivalents
01-30 days	$3	$18	$46
31-60 days	$6	$36	$92
61-90 days	$9	$54	$138

MAIL ORDER COPAYMENT AMOUNTS Up to a 90-day Supply
Supply	Generic	Brand Name Drug without generic equivalents	Brand Name Drug with generic equivalents
01-90 days	$5	$36	$92

Aetna Value HD1500, NJ DIRECT HD1500, Aetna Value HD4000, NJ DIRECT HD4000

Under the High Deductible Health Plans (HDHP) prescription drug benefits are subject to the HDHP deductible and coinsurance. See your plan handbook or contact your HDHP directly for details.

Note: In certain circumstances of intolerance or the therapeutic failure of a drug's generic equivalent, a member may be able to receive a third tier brand name drug where a generic equivalent is available for the lower second tier copayment for a brand name drug without generic equivalent.

If you have any questions regarding this information, contact the Office of Client Services at
(609) 292-7524 or send an e-mail using the "contact us" link below.

LOCAL GOVERNMENT EMPLOYEES ENROLLED IN THE SHBP

Employee Prescription Drug Plan copayments for Plan Year 2013

Copayments are based on the medical plan in which the employee is enrolled

Aetna Freedom10, NJ DIRECT10, Aetna Freedom15, NJ DIRECT15, Aetna HMO, or Horizon HMO | 1525 Plans | 2030 Plans | High Deductible Health Plans

Aetna Freedom10, NJ DIRECT10, Aetna Freedom15, NJ DIRECT15, Aetna HMO, Horizon HMO

RETAIL PHARMACY COPAYMENT AMOUNTS Up to a 90-day Supply
Supply	Generic	Preferred Brand Name Drug	Non-Preferred Brand Name Drug
01-30 days	$3	$10	$10
31-60 days	$6	$20	$20
61-90 days	$9	$30	$30

MAIL ORDER COPAYMENT AMOUNTS Up to a 90-day Supply
Supply	Generic	Preferred Brand Name Drug	Non-Preferred Brand Name Drug
01-90 days	$5	$15	$15

Aetna Freedom 1525, NJ DIRECT1525, Aetna HMO1525, Horizon HMO1525

RETAIL PHARMACY COPAYMENT AMOUNTS Up to a 90-day Supply
Supply	Generic	Preferred Brand Name Drug	Non-Preferred Brand Name Drug
01-30 days	$7	$16	$35
31-60 days	$14	$32	$70
61-90 days	$21	$48	$105

MAIL ORDER COPAYMENT AMOUNTS Up to a 90-day Supply
Supply	Generic	Preferred Brand Name Drug	Non-Preferred Brand Name Drug
01-90 days	$18	$40	$88

Aetna Freedom2030, NJ DIRECT2030, Aetna HMO2030, Horizon HMO2030

RETAIL PHARMACY COPAYMENT AMOUNTS Up to a 90-day Supply
Supply	Generic	Preferred Brand Name Drug	Non-Preferred Brand Name Drug
01-30 days	$3	$18	$46
31-60 days	$6	$36	$92
61-90 days	$9	$54	$138

MAIL ORDER COPAYMENT AMOUNTS Up to a 90-day Supply
Supply	Generic	Preferred Brand Name Drug	Non-Preferred Brand Name Drug
01-90 days	$5	$36	$92

Aetna Value HD1500, NJ DIRECT HD1500, Aetna Value HD4000, NJ DIRECT HD4000

Under the High Deductible Health Plans (HDHP) prescription drug benefits are subject to the HDHP deductible and coinsurance. See your plan handbook or contact your HDHP directly for details.

If you have any questions regarding this information, contact the Office of Client Services at
(609) 292-7524 or send an e-mail using the "contact us" link below.

LOCAL EDUCATION EMPLOYEES ENROLLED IN THE SEHBP

Employee Prescription Drug Plan copayments for Plan Year 2013

Copayments are based on the medical plan in which the employee is enrolled

Aetna Freedom10, NJ DIRECT10, Aetna Freedom15, NJ DIRECT15, Aetna HMO, or Horizon HMO | 1525 Plans | 2030 Plans | High Deductible Health Plans

Aetna Freedom10, NJ DIRECT10, Aetna Freedom15, NJ DIRECT15, Aetna HMO, Horizon HMO

RETAIL PHARMACY COPAYMENT AMOUNTS Up to a 90-day Supply
Supply	Generic	Preferred Brand Name Drug	Non-Preferred Brand Name Drug
01-30 days	$3	$10	$10
31-60 days	$6	$20	$20
61-90 days	$9	$30	$30

MAIL ORDER COPAYMENT AMOUNTS Up to a 90-day Supply
Supply	Generic	Preferred Brand Name Drug	Non-Preferred Brand Name Drug
01-90 days	$5	$15	$15

Aetna Freedom 1525, NJ DIRECT1525, Aetna HMO1525, Horizon HMO1525

RETAIL PHARMACY COPAYMENT AMOUNTS Up to a 90-day Supply
Supply	Generic	Preferred Brand Name Drug	Non-Preferred Brand Name Drug
01-30 days	$7	$16	$35
31-60 days	$14	$32	$70
61-90 days	$21	$48	$105

MAIL ORDER COPAYMENT AMOUNTS Up to a 90-day Supply
Supply	Generic	Preferred Brand Name Drug	Non-Preferred Brand Name Drug
01-90 days	$18	$40	$88

Aetna Freedom2030, NJ DIRECT2030, Aetna HMO2030, Horizon HMO2030

RETAIL PHARMACY COPAYMENT AMOUNTS Up to a 90-day Supply
Supply	Generic	Preferred Brand Name Drug	Non-Preferred Brand Name Drug
01-30 days	$3	$18	$46
31-60 days	$6	$36	$92
61-90 days	$9	$54	$138

MAIL ORDER COPAYMENT AMOUNTS Up to a 90-day Supply
Supply	Generic	Preferred Brand Name Drug	Non-Preferred Brand Name Drug
01-90 days	$5	$36	$92

Aetna Value HD1500, NJ DIRECT HD1500

Under the High Deductible Health Plans (HDHP) prescription drug benefits are subject to the HDHP deductible and coinsurance. See your plan handbook or contact your HDHP directly for details.

If you have any questions regarding this information, contact the Office of Client Services at
(609) 292-7524 or send an e-mail using the "contact us" link below.

Last update: September 25, 2012

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STATE HEALTH BENEFITS PROGRAM and SCHOOL EMPLOYEES' HEALTH BENEFITS PROGRAMEMPLOYEE PRESCRIPTION DRUG PLAN COPAYMENTS

STATE HEALTH BENEFITS PROGRAM and
SCHOOL EMPLOYEES' HEALTH BENEFITS PROGRAM
EMPLOYEE PRESCRIPTION DRUG PLAN COPAYMENTS