T2679 Exhibit C - Retiree Drug Plan 10.23.25.pdf

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Attached to
T2679 - Employee Benefits: Pharmacy Benefits Management
Solicitation number
25DPP01133
Issued by
Mercer County, New Jersey

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Written by GovTribe AI ·

This document is an Exhibit C Retiree Drug Plan from the New Jersey Division of Pensions & Benefits (NJDPB) detailing pharmacy benefits management for various retired employee groups for Plan Year 2024. The exhibit provides comprehensive prescription plan design comparisons across multiple benefit groups including the State Retired Group, State CWA Retired Group, Local Government Retired Group, Local Education Retired Group, State Health Benefits Program (SHBP), and School Employees' Health Benefits Program (SEHBP). The plans feature different prescription drug copayment structures for retail and mail-order pharmacies, categorized by generic, preferred brand, and non-preferred brand medications, with consistent annual out-of-pocket maximums ranging from $1,351/$2,702 to $1,600/$3,200 depending on the specific group.

The prescription plans are offered through multiple providers including Aetna and Horizon, with varying copayment levels across different plan tiers such as Freedom, NJ DIRECT, HMO, and Medicare Advantage options. Copayments for generic medications range from $3 to $10 at retail, while preferred brand medications range from $10 to $22, and non-preferred brand medications from $24 to $46. Mail-order prescriptions generally have lower copayments, with generic medications consistently around $5. The plans also include provisions for brand medications with generic equivalents, where members pay the cost difference between brand and generic drugs. Medicare-eligible retirees are automatically enrolled in corresponding Medicare Advantage plans, with specific service area limitations noted for Horizon HMO plans, which are primarily restricted to New Jersey and select surrounding counties.

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T2679 25DPP01133 Employee Benefits: Pharmacy Benefits Management

EXHIBIT C - RETIREE DRUG PLAN

STATE RETIRED GROUP

PRESCRIPTION PLAN DESIGN - PLAN YEAR 2024

HR-1158-0524

Side-by-Side Rx Comparison Aetna

Freedom Horizon

NJ DIRECT

Aetna

Freedom10 Horizon

NJ DIRECT10

Aetna

Freedom15 Horizon

NJ DIRECT15

Retail: Generic Copayments $7 $7 $10 $10 $10 $10

Retail: Preferred Brand Copayments $16 $16 $22 $22 $22 $22

Retail: Non-Preferred Brand Copayments $35 $35 $44 $44 $44 $44

Retail: Brand w/ Generic Equivalent1

Member pays difference

Member pays difference

Member pays difference

Member pays difference

Member pays difference

Member pays difference

Mail: Generic Copayments $18 $18 $5 $5 $5 $5

Mail: Preferred Brand Copayments $40 $40 $28 $28 $28 $28

Mail: Non-Preferred Brand Copayments $88 $88 $55 $55 $55 $55

Mail: Brand w/ Generic Equivalent1

Member pays difference

Member pays difference

Member pays difference

Member pays difference

Member pays difference

Member pays difference

Prescription Drug annual Out-of-Pocket Maximum (Individual/ Family)

$1,351/$2,702 $1,351/$2,702 $1,351/$2,702 $1,351/$2,702 $1,351/$2,702 $1,351/$2,702

EXHIBIT C- RETIREE DRUG PLAN

STATE RETIRED GROUP

PRESCRIPTION PLAN DESIGN - PLAN YEAR 2024

HR-1158-0524

Side-by-Side Rx Comparison Aetna

Freedom1525 Horizon

NJ DIRECT1525

Aetna

Freedom2030 Horizon

NJ DIRECT2030 Aetna HMO2 Horizon HMO2

Retail: Generic Copayments $7 $7 $3 $3 $6 $6

Retail: Preferred Brand Copayments $16 $16 $18 $18 $12 $12

Retail: Non-Preferred Brand Copayments $35 $35 $46 $46 $24 $24

Retail: Brand w/ Generic Equivalent1

Member pays difference

Member pays difference

Member pays difference

Member pays difference

Member pays difference

Member pays difference

Mail: Generic Copayments $5 $5 $5 $5 $5 $5

Mail: Preferred Brand Copayments $40 $40 $36 $36 $18 $18

Mail: Non-Preferred Brand Copayments $88 $88 $92 $92 $30 $30

Mail: Brand w/ Generic Equivalent1

Member pays difference

Member pays difference

Member pays difference

Member pays difference

Member pays difference

Member pays difference

Prescription Drug annual Out-of-Pocket Maximum (Individual/ Family)

STATE RETIRED GROUP

PRESCRIPTION PLAN DESIGN - PLAN YEAR 2024

HR-1158-0524

Side-by-Side Rx Comparison Aetna

HMO15252

Horizon

HMO15252

Aetna

HMO20302

Horizon

HMO20302

Aetna

Liberty Plus Horizon OMNIA Retail: Generic Copayments $7 $7 $3 $3 $7 $7

Retail: Preferred Brand Copayments $16 $16 $18 $18 $16 $16

Retail: Non-Preferred Brand Copayments $35 $35 $46 $46 $35 $35

Retail: Brand w/ Generic Equivalent1

Member pays difference

Member pays difference

Member pays difference

Member pays difference

Member pays difference

Member pays difference

Mail: Generic Copayments $5 $5 $5 $5 $18 $18

Mail: Preferred Brand Copayments $40 $40 $36 $36 $40 $40

Mail: Non-Preferred Brand Copayments $88 $88 $92 $92 $88 $88

Mail: Brand w/ Generic Equivalent1

Member pays difference

Member pays difference

Member pays difference

Member pays difference

Member pays difference

Member pays difference

Prescription Drug annual Out-of-Pocket Maximum (Individual/

STATE RETIRED GROUP

PRESCRIPTION PLAN DESIGN - PLAN YEAR 2024

HR-1158-0524

Side-by-Side Rx Comparison Aetna

Freedom HDHigh Horizon

NJ DIRECT HDHigh Aetna

Freedom HDLow Horizon

NJ DIRECT HDLow Retail: Generic Copayments

Subject to deductible and coinsurance

Subject to deductible and coinsurance

Subject to deductible and coinsurance

Subject to deductible and coinsurance

Retail: Preferred Brand Copayments Retail: Non-Preferred Brand Copayments Retail: Brand w/ Generic Equivalent Mail: Generic Copayments Mail: Preferred Brand Copayments Mail: Non-Preferred Brand Copayments Mail: Brand w/ Generic Equivalent Prescription Drug annual Out-of-Pocket Maximum (Individual/ Family)

1You pay the cost difference between the brand drug and the generic drug.
2Service areas for Horizon HMO plans are limited to New Jersey, New Castle County in Delaware, and bordering counties of Pennsylvania and New York. Aetna HMO plans are not limited to this service area and utilize Aet-

na’s nationwide Aetna Select network.

This publication is produced and distributed by the New Jersey Division of Pensions & Benefits — www.nj.gov/treasury/pensions This is a summary and not intended to provide all information. Although every attempt at accuracy is made, it cannot be guaranteed.

STATE CWA RETIRED GROUP

PRESCRIPTION PLAN DESIGN - PLAN YEAR 2024

HR-1159-0524

This chart is only for members represented by the Communications Workers of America (CWA).

Side-by-Side Rx Comparison Aetna

Freedom Unity Direct Horizon

CWA NJ DIRECT Aetna HMO1 Horizon HMO1

Retail: Generic Copayments $7 $7 $6 $6

Retail: Preferred Brand Copayments $16 $16 $12 $12

Retail: Non-Preferred Brand Copayments $35 $35 $24 $24

Retail: Brand w/ Generic Equivalent2 Member pays difference Member pays difference Member pays difference Member pays difference

Mail: Generic Copayments $18 $18 $5 $5

Mail: Preferred Brand Copayments $40 $40 $18 $18

Mail: Non-Preferred Brand Copayments $88 $88 $30 $30

Mail: Brand w/ Generic Equivalent2 Member pays difference Member pays difference Member pays difference Member pays difference

Prescription Drug annual Out-of-Pocket Maximum (Individual/Family) $1,351/$2,702 $1,351/$2,702 $1,351/$2,702 $1,351/$2,702

STATE CWA RETIRED GROUP

PRESCRIPTION PLAN DESIGN - PLAN YEAR 2024

HR-1159-0524

This chart is only for members represented by the Communications Workers of America (CWA).

Side-by-Side Rx Comparison Aetna

Liberty Plus Horizon OMNIA Aetna

Freedom HDHigh Horizon

NJ DIRECT HDHigh

Retail: Generic Copayments $7 $7

Subject to deductible and coinsurance

Subject to deductible and coinsurance

Retail: Preferred Brand Copayments $16 $16

Retail: Non-Preferred Brand Copayments $35 $35

Retail: Brand w/ Generic Equivalent2 Member pays difference Member pays difference

Mail: Generic Copayments $18 $18

Mail: Preferred Brand Copayments $40 $40

Mail: Non-Preferred Brand Copayments $88 $88

Mail: Brand w/ Generic Equivalent2 Member pays difference Member pays difference

(Individual/Family) $1,351/$2,702 $1,351/$2,702

STATE CWA RETIRED GROUP

PRESCRIPTION PLAN DESIGN - PLAN YEAR 2024

HR-1159-0524

This chart is only for members represented by the Communications Workers of America (CWA).

Side-by-Side Rx Comparison Aetna

Freedom HDLow Horizon

NJ DIRECT HDLow

Retail: Generic Copayments

Subject to deductible and coinsurance

Subject to deductible and coinsurance

Retail: Preferred Brand Copayments

Retail: Non-Preferred Brand Copayments

Retail: Brand w/ Generic Equivalent Mail: Generic Copayments

Mail: Preferred Brand Copayments

Mail: Non-Preferred Brand Copayments

Mail: Brand w/ Generic Equivalent Prescription Drug annual Out-of-Pocket Maximum (Individual/Family)

1 Service areas for Horizon HMO plans are limited to New Jersey, New Castle County in Delaware, and bordering counties of Pennsylvania and New York. Aetna HMO plans are not limited to this service area and utilize Aet-na’s nationwide Aetna Select network.

2 You pay the cost difference between the brand drug and the generic drug.

This publication is produced and distributed by the New Jersey Division of Pensions & Benefits — www.nj.gov/treasury/pensions This is a summary and not intended to provide all information. Although every attempt at accuracy is made, it cannot be guaranteed.

Note: Retail – 30 day supply. Mail – 90 day supply.

UNION NEGOTIATED PLANS - RETIRED GROUP PRESCRIPTION PLAN

DESIGN - PLAN YEAR 2024

HR-1160-0524

This chart is only for retirees covered under certain negotiated labor agreements.

Side-by-Side Rx Comparison AetnaFreedom Holrizon NJ DIRECT Aetna HMO1 Horizon HMO1

Retail: Generic Copayments $7 $7 $6 $6

Retail: Preferred Brand Copayments $16 $16 $12 $12

Retail: Non-Preferred Brand Copayments $35 $35 $24 $24

Retail: Brand w/ Generic Equivalent2 Member pays difference Member pays difference Member pays difference Member pays difference

Mail: Generic Copayments $18 $18 $5 $5

Mail: Preferred Brand Copayments $40 $40 $18 $18

Mail: Non-Preferred Brand Copayments $88 $88 $30 $30

Mail: Brand w/ Generic Equivalent2 Member pays difference Member pays difference Member pays difference Member pays difference

(Individual/Family) $1,351/$2,702 $1,351/$2,702 $1,351/$2,702 $1,351/$2,702

UNION NEGOTIATED PLANS - RETIRED GROUP PRESCRIPTION PLAN

DESIGN - PLAN YEAR 2024

HR-1160-0524

This chart is only for retirees covered under certain negotiated labor agreements.

Side-by-Side Rx Comparison Aetna Liberty Plus Horizon OMNIA Aetna

Freedom HDHigh* Horizon

NJ DIRECT HDHigh*

Retail: Generic Copayments $7 $7

Subject to deductible and coinsurance

Subject to deductible and coinsurance

Retail: Preferred Brand Copayments $16 $16

Retail: Non-Preferred Brand Copayments $35 $35

Retail: Brand w/ Generic Equivalent2 Member pays difference Member pays difference

Mail: Generic Copayments $18 $18

Mail: Preferred Brand Copayments $40 $40

Mail: Non-Preferred Brand Copayments $88 $88

Mail: Brand w/ Generic Equivalent2 Member pays difference Member pays difference

(Individual/Family) $1,351/$2,702 $1,351/$2,702

UNION NEGOTIATED PLANS - RETIRED GROUP PRESCRIPTION PLAN

DESIGN - PLAN YEAR 2024

HR-1160-0524

This chart is only for retirees covered under certain negotiated labor agreements.

1 Service areas for Horizon HMO plans are limited to New Jersey, New Castle County in Delaware, and bordering counties of Pennsylvania and New York. Aetna HMO plans are not limited to this service area and utilize Aet-na’s nationwide Aetna Select network.

2 You pay the cost difference between the brand drug and the generic drug.

This publication is produced and distributed by the New Jersey Division of Pensions & Benefits — www.nj.gov/treasury/pensions This is a summary and not intended to provide all information. Although every attempt at accuracy is made, it cannot be guaranteed.

Note: Retail – 30 day supply. Mail – 90 day supply.

Side-by-Side Rx Comparison Aetna

Freedom HDLow* Horizon

NJ DIRECT HDLow*

Retail: Generic Copayments

Subject to deductible and coinsurance

Subject to deductible and coinsurance

Retail: Preferred Brand Copayments

Retail: Non-Preferred Brand Copayments

Retail: Brand w/ Generic Equivalent Mail: Generic Copayments

Mail: Preferred Brand Copayments

Mail: Non-Preferred Brand Copayments

Mail: Brand w/ Generic Equivalent

(Individual/Family)

LOCAL GOVERNMENT RETIRED GROUP PRESCRIPTION PLAN DESIGN -

PLAN YEAR 2024

HR-1161-0524

Side-by-Side Rx Comparison Aetna

Freedom Horizon

NJ DIRECT

Aetna

Freedom10 Horizon

NJ DIRECT10

Aetna

Freedom15 Horizon

NJ DIRECT15

Retail: Generic Copayments $7 $7 $10 $10 $10 $10

Retail: Preferred Brand Copayments $16 $16 $22 $22 $22 $22

Retail: Non-Preferred Brand Copayments $35 $35 $44 $44 $44 $44

Retail: Brand w/ Generic Equivalent1 Member pays difference Member pays difference Member pays difference Member pays difference Member pays difference Member pays difference

Mail: Generic Copayments $18 $18 $5 $5 $5 $5

Mail: Preferred Brand Copayments $40 $40 $28 $28 $28 $28

Mail: Non-Preferred Brand Copayments $88 $88 $55 $55 $55 $55

Mail: Brand w/ Generic Equivalent1 Member pays difference Member pays difference Member pays difference Member pays difference Member pays difference Member pays difference Prescription Drug annual Out-of-Pocket Maximum (Individual/Family) $1,351/$2,702 $1,351/$2,702 $1,351/$2,702 $1,351/$2,702 $1,351/$2,702 $1,351/$2,702

LOCAL GOVERNMENT RETIRED GROUP PRESCRIPTION PLAN DESIGN -

PLAN YEAR 2024

HR-1161-0524

Side-by-Side Rx Comparison Aetna

Freedom1525 Horizon

NJ DIRECT1525

Aetna

Freedom2030 Horizon

NJ DIRECT2030 Aetna HMO2 Horizon HMO2

Retail: Generic Copayments $7 $7 $3 $3 $6 $6

Retail: Preferred Brand Copayments $16 $16 $18 $18 $12 $12

Retail: Non-Preferred Brand Copayments $35 $35 $46 $46 $24 $24

Retail: Brand w/ Generic Equivalent1 Member pays difference Member pays difference Member pays difference Member pays difference Member pays difference Member pays difference

Mail: Generic Copayments $5 $5 $5 $5 $5 $5

Mail: Preferred Brand Copayments $40 $40 $36 $36 $18 $18

Mail: Non-Preferred Brand Copayments $88 $88 $92 $92 $30 $30

Mail: Brand w/ Generic Equivalent1 Member pays difference Member pays difference Member pays difference Member pays difference Member pays difference Member pays difference

Maximum (Individual/Family) $1,351/$2,702 $1,351/$2,702 $1,351/$2,702 $1,351/$2,702 $1,351/$2,702 $1,351/$2,702

LOCAL GOVERNMENT RETIRED GROUP PRESCRIPTION PLAN DESIGN -

PLAN YEAR 2024

HR-1161-0524

Side-by-Side Rx Comparison Aetna

HMO15252

Horizon

HMO15252

Aetna

HMO20301

Horizon

HMO20301

Aetna

Liberty Plus Horizon OMNIA Retail: Generic Copayments $7 $7 $3 $3 $7 $7

Retail: Preferred Brand Copayments $16 $16 $18 $18 $16 $16

Retail: Non-Preferred Brand Copayments $35 $35 $46 $46 $35 $35

Retail: Brand w/ Generic Equivalent1 Member pays difference Member pays difference Member pays difference Member pays difference Member pays difference Member pays difference

Mail: Generic Copayments $5 $5 $5 $5 $18 $18

Mail: Preferred Brand Copayments $40 $40 $36 $36 $40 $40

Mail: Non-Preferred Brand Copayments $88 $88 $92 $92 $88 $88

Mail: Brand w/ Generic Equivalent1 Member pays difference Member pays difference Member pays difference Member pays difference Member pays difference Member pays difference

Maximum (Individual/Family) $1,351/$2,702 $1,351/$2,702 $1,351/$2,702 $1,351/$2,702 $1,351/$2,702 $1,351/$2,702

LOCAL GOVERNMENT RETIRED GROUP PRESCRIPTION PLAN DESIGN -

PLAN YEAR 2024

HR-1161-0524

1You pay the cost difference between the brand drug and the generic drug.
2Service areas for Horizon HMO plans are limited to New Jersey, New Castle County in Delaware, and bordering counties of Pennsylvania and New York. Aetna HMO plans are not limited to this service area and utilize Aet-

na’s nationwide Aetna Select network.

This publication is produced and distributed by the New Jersey Division of Pensions & Benefits — www.nj.gov/treasury/pensions This is a summary and not intended to provide all information. Although every attempt at accuracy is made, it cannot be guaranteed.

Note: Retail – 30 day supply. Mail – 90 day supply.

Side-by-Side Rx Comparison Aetna

Freedom HDHigh Horizon

NJ Direct HDHigh Aetna

Freedom HDLow Horizon

NJ Direct HDLow Retail: Generic Copayments

Subject to deductible and coinsurance

Subject to deductible and coinsurance

Subject to deductible and coinsurance

Subject to deductible and coinsurance

Retail: Preferred Brand Copayments Retail: Non-Preferred Brand Copayments

Retail: Brand w/ Generic Equivalent

Mail: Generic Copayments

Mail: Preferred Brand Copayments Mail: Non-Preferred Brand Copayments

Mail: Brand w/ Generic Equivalent

Maximum (Individual/Family)

State Health Benefits Program (SHBP)

PRESCRIPTION PLAN DESIGN - PLAN YEAR 2024

MEDICARE ADVANTAGE AND MEDICARE SUPPLEMENTAL GROUP PLANS

HR-1163-0524

Aetna Medicare Advantage Plans

Side-by-Side Rx Comparison

Medicare Advantage

PPO ESA 10

(Freedom 10)

Medicare Advantage

PPO ESA 15

(Freedom 15)

Medicare Advantage

Open Access

HMO (HMO)

Medicare Advantage

Open Access

HMO 1525

(HMO 1525)

Retail: Generic Copayments $10 $10 $6 $7

Retail: Preferred Brand Copay-ments $22 $22 $12 $16

Retail: Non-Preferred Brand Copayments $44 $44 $24 $35

Mail: Generic Copayments1 $5 $5 $5 $5

Mail: Preferred Brand Copay-ments1 $28 $28 $18 $40

Mail: Non-Preferred Brand Copayments1 $55 $55 $30 $88

Prescription Drug annual Out-of-Pocket Maximum (Individual/

$1,351/$2,702 $1,351/$2,702 $1,351/$2,702 $1,351/$2,702

State Health Benefits Program (SHBP)

PRESCRIPTION PLAN DESIGN - PLAN YEAR 2024

MEDICARE ADVANTAGE AND MEDICARE SUPPLEMENTAL GROUP PLANS

HR-1163-0524

This publication is produced and distributed by the New Jersey Division of Pensions & Benefits (NJDPB) – www.nj.gov/treasury/pensions This is a summary and not intended to provide total information. Although every attempt at accuracy is made, it cannot be guaranteed.

Note: Mail Order copay amounts are for prescriptions up to 90 days.

1 30-day copays for Specialty Pharmacy in the Employer Group Waiver Plan (EGWP) range from $1 for generic, $6-$13 for preferred brand, and $10-$30 for non-preferred brand depending on retiree plan option.

Horizon Medicare Supplemental Plans

Side-by-Side Rx Comparison NJ DIRECT1525 NJ DIRECT2030 Horizon HMO Horizon

HMO1525

Horizon

HMO2030

Retail: Generic Copayments $7 $3 $6 $7 $3

Retail: Preferred Brand Copayments $16 $18 $12 $16 $18

Retail: Non-Preferred Brand Copayments $35 $46 $24 $35 $46

Mail: Generic Copayments1 $5 $5 $5 $5 $5

Mail: Preferred Brand Copayments1 $40 $36 $18 $40 $36

Mail: Non-Preferred Brand Copayments1 $88 $92 $30 $88 $92

Prescription Drug annual Out-of-Pocket Maximum (Individual/ Family)

$1,351/$2,702 $1,351/$2,702 $1,351/$2,702 $1,351/$2,702 $1,351/$2,702 http://www.nj.gov/treasury/pensions

T2679 25DPP01133 Employee Benefits: Pharmacy Benefits Management

EXHIBIT C - RETIREE DRUG PLAN

LOCAL EDUCATION RETIRED GROUP

PRESCRIPTION PLAN DESIGN - PLAN YEAR 2024

HR-1162-0524

Side-by-Side Rx Comparison Aetna NJEHP Horizon NJEHP

Aetna Garden State Health Plan

(GSHP)

Retail: Generic Copayments $5 $5 $5 Retail: Preferred Brand Copayments $10 $10 $10

Retail: Non-Preferred Brand Copayments

Member pays difference between generic copayment listed plus cost difference between brand and generic

Member pays difference between generic copayment listed plus cost difference between brand and generic

Member pays difference between generic copayment listed plus cost difference between brand and generic

Mail: Generic Copayments $10 $10 $10 Mail: Preferred Brand Copayments $20 $20 $20

Mail: Non-Preferred Brand Copayments

Member pays difference between generic copayment listed plus cost difference between brand and generic

Member pays difference between generic copayment listed plus cost difference between brand and generic

Member pays difference between generic copayment listed plus cost difference between brand and generic

Prescription Drug annual Out-of-Pocket Maximum (Individual/Family)

$1,600/$3,200 $1,600/$3,200 $1,600/$3,200

Note: Medicare-eligible retirees and/or Medicare eligible spouses of retirees will be enrolled in a corresponding plan. Medicare enrollees can review the Medicare Advantage plan designs on Aetna’s website: www.aetnastatenj.com

This publication is produced and distributed by the New Jersey Division of Pensions & Benefits — www.nj.gov/treasury/pensions This is a summary and not intended to provide all information. Although every attempt at accuracy is made, it cannot be guaranteed.

School Employees’ Health Benefits Program (SEHBP) PRESCRIPTION

PLAN DESIGN - PLAN YEAR 2024

MEDICARE ADVANTAGE AND MEDICARE SUPPLEMENTAL GROUP PLANS

HR-1164-0524

Side-by-Side Rx Comparison

Aetna Medicare Advantage Plans

Medicare Advantage

PPO ESA 10

(Freedom 10)

Medicare Advantage

PPO ESA 15

(Freedom 15)

Medicare Advantage

Open Access

HMO (HMO)

Medicare Advantage

Open Access

HMO 1525

(HMO 1525)

Retail: Generic Copayments $10 $10 $6 $7

Retail: Preferred Brand Copayments $21 $21 $13 $17

Retail: Non-Preferred Brand Copayments $42 $42 $26 $36

Mail: Generic Copayments $5 $5 $5 $5

Mail: Preferred Brand Copayments $31 $31 $19 $41

Mail: Non-Preferred Brand Copayments $52 $52 $31 $91

Prescription Drug annual Out-of-Pocket Maximum (Individual/

$1,411/$2,822 $1,411/$2,822 $1,411/$2,822 $1,411/$2,822

School Employees’ Health Benefits Program (SEHBP) PRESCRIPTION

PLAN DESIGN - PLAN YEAR 2024

MEDICARE ADVANTAGE AND MEDICARE SUPPLEMENTAL GROUP PLANS

HR-1164-0524

This publication is produced and distributed by the New Jersey Division of Pensions & Benefits (NJDPB) – www.nj.gov/treasury/pensions This is a summary and not intended to provide total information. Although every attempt at accuracy is made, it cannot be guaranteed.

Side-by-Side Rx Comparison

Horizon Medicare Supplemental Plans

NJ DIRECT1525 NJ DIRECT2030 Horizon HMO Horizon

HMO1525

Horizon

HMO2030

Retail: Generic Copayments $7 $3 $6 $7 $3

Retail: Preferred Brand Copayments $17 $19 $13 $17 $19

Retail: Non-Preferred Brand Copayments $36 $48 $26 $36 $48

Mail: Generic Copayments $5 $5 $5 $5 $5

Mail: Preferred Brand Copayments $41 $37 $19 $41 $37

Mail: Non-Preferred Brand Copayments $91 $95 $31 $91 $95

Prescription Drug annual Out-of-Pocket Maximum (Individual/ Family)

$1,411/$2,822 $1,411/$2,822 $1,411/$2,822 $1,411/$2,822 $1,411/$2,822

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