Update on OptumRX and the NJ State Health Benefit Plan

Last week the New Jersey Appellate Court ruled that the pharmacy benefit management (PBM) contract for the New Jersey State Health Benefit Plan will have to be rebid.  OptumRX is the current plan manager and will continue to administer the health plan while the state decides whether to appeal the Appellate Court decision.

In the meantime please be aware of your right to appeal any denials from OptumRX.  See the below information that state employees should be aware of:

WHEN IN DOUBT, APPEAL

  • Changes in administrators to the prescription drug program result in changes in formularies and sometimes a little different enforcement of state health benefits drug plan rules.
  • This can mean that members are asked to change drugs or some prescriptions are denied. If this presents a medical problem, members should consider working with their doctor to appeal the decision of the pharmacy benefit manager, which is Optum RX for the time being.
  • Members are winning approximately 70% of appeals to Optum RX which relate to quantity limits and drug exclusions, so appeals can be helpful to members.

Here’s a link to an article about the court ruling mandating that the PBM contract be rebid:

http://www.nj.com/politics/index.ssf/2018/05/nj_court_kills_67b_contract_prescription_drug_cont.html