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Pensions and Benefits
STATE HEALTH BENEFITS PROGRAM and
SCHOOL EMPLOYEES' HEALTH BENEFITS PROGRAM

EMPLOYEE PRESCRIPTION DRUG PLAN COPAYMENTS

STATE EMPLOYEES ENROLLED IN THE SHBP

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 Freedom2035, NJ DIRECT2035, Aetna HMO2035, Horizon HMO2035

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 $21 Member pays difference*
31-60 days $14 $42 Member pays difference*
61-90 days $21 $63 Member pays difference*


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 $52 Member pays difference*

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

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 GOVERNMENT EMPLOYEES ENROLLED IN THE SHBP

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 Freedom2035, NJ DIRECT2035, Aetna HMO2035, Horizon HMO2035

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 $21 Member pays difference*
31-60 days $14 $42 Member pays difference*
61-90 days $21 $63 Member pays difference*


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 $52 Member pays difference*

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

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

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 Freedom2035, NJ DIRECT2035, Aetna HMO2035, Horizon HMO2035

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 $21 Member pays difference*
31-60 days $14 $42 Member pays difference*
61-90 days $21 $63 Member pays difference*


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 $52 Member pays difference*

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

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.

 
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