Appendix C - City of Jersey City - Rx Grid Summary.pdf
PDF 138 KB Posted
- Solicitation number
- RFP_F - 25
- Issued by
- Hudson County, New Jersey
About this file
This document is an Express Scripts Rx Benefits Grid for the City of Jersey City, covering prescription drug benefits for various active and retiree plans across multiple employee groups including Local 245, Local 246, JCSA, Management, Police Superiors, Fire Superiors, Fire Fighters, POBA, COBRA, JCEDC, and Library. The grid details prescription drug coverage options for retail and mail order pharmacy services, with different copayment tiers for generic, brand name, and non-formulary medications across different plan types.
The benefits grid provides specific copayment amounts for different drug categories, with variations based on the specific employee group and whether it's an active or retiree plan. Key features include mandatory mail order for maintenance drugs, mandatory generic substitution, and a formulary with dispense quantity management. High-cost drug tiers are also included, with copayments for drugs costing over $1,000, $2,000, and $3,000. Maximum out-of-pocket costs are specified for retiree plans, with RET A capped at $1,082 and RET C at $1,351. The document is dated and updated for May 2025, indicating a current and comprehensive overview of prescription drug benefits for Jersey City employees.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Retail Generic
Brand
Non-Formulary
Mail Order Generic
Generic >30
Brand
Brand >30
Non-Formulary
Non-Formulary >30
High Cost Drugs Cost >$3000
Cost >$2,000
Cost > $1,000
Maximum Out of Pocket
Mandatory Mail Order for
Maintenance Drugs
Mandatory Generic
Formulary
Dispense Quantity
Management
Basic
Fire Superiors
POBA
Fire Fighters
ACTIVE PLANS RETIREE PLANS
RET A
RET C
EGWP
The City of Jersey City Express Scripts - Rx Benefits Grid
Local 245
68-68A
COBRA
Local 246
JCSA
Management
Police Superiors
Basic
NPF NPF NPF Basic Basic Basic
RET A: $1,082
RET C: $1,351
Prescription Management Programs
$100 $100 $100
$50 $50 $50
$150 $150 $150 Applicable Tier
Copay
Applicable Tier
Copay
Applicable Tier
Copay
Applicable Tier
Copay
Applicable Tier
Copay
$42 $42
$35 $35 $35 $70 $50 $25 $42 $42
$35 $35 $35 $70 $50 $25
$25 $25
$25 $25 $25 $40 $35 $15
$25 $25 $25 $40 $35 $15 $25 $25
$8 $8
$5 $5 $5 $20 $5 $5 $8 $8
$5 $5 $5 $20 $5 $5
$17 $17
$35 $35 $35 $35 $20 $20 $34 $34
$25 $25 $25 $20 $15 $10
$5 $5 $5 $10 $2 $5 $8 $8
JCEDC Library RET B
UUpdated May 2025
File details come from the government source that posted it. Updated .