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   Dear NJLM Health Benefits Task Force Member,

   Below is a listing of suggestions that Plan Design Committee members from both the State representatives and labor representatives put forth to achieve $100 million in savings for the state SHBP Plan Year 2026.  Please let us know for each recommendation if you support the recommendation, oppose the recommendation, or are neutral on the recommendation. 

6. Plan Changes
8. Eliminate all current plans and replace them with two plans - a modified Unity PPO and a modified Tiered Network Plan*

   1. Support Recommendation
   2. Oppose Recommendation
   3. Neutral
   4. Other (please describe below)
10. Retain all current SHBP state plans and increase the deductibles and out-of- pocket maximum amounts across all plans for both in-network and out-of-network care *

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
12. Implement spousal surcharge of $50/month for members with spouses who have access to other health benefits coverage through their own employers but uses the SHBP plan *

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
14. Eliminate the Medicare Supplement plans and migrate State members to the Medicare Advantage PPO15 plan option *

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
16. Limit physical therapy and chiropractic visits for all plans to 30 per year, each*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
18. Revise rate recommendation to be issued for the State group no later than August 15, 2025*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
20. Outcomes and agreements from the NJ State bargaining unit reopener tables that require PDC approval shall be credited towards the FY2026 budget requirement and shall be scored to reduce premiums for PY2026*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
22. Claims Review – Mandate review of no less than 50% of all claims, in and out of network, and at least 50% of out of state claims*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
24. Implement Reference Based Pricing across all SHBP Plans at 200% of CMS in- and out-of-network and prohibiting balance billing*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
26. Provide incentives attached to lower cost plans, including HDHPs, by offering lower employee contribution rates and increase HRA and HAS Plans*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
28. Require and audit appropriate emergency room coding*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
30. Evaluate Care Management Programs that are not generating ROI and renegotiate prices or terminate*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
32. Competitive Plan Premium Rates (separate premium rates analyses for the two medical plans - Horizon & Aetna)*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
34. If you answer "other" above, please expand upon the comments below or feel free to add additional comments on the recommendations for Plan Design changes?
36. Plan: Center of Excellence (COE)
38. Expand the pending Centers of Excellence Pilot Program to include two more covered procedures (routine colonoscopies and one other procedure from a list of possible options) and change the member cost-share in years one and two of that Pilot Program to incentivize utilization of the Center of Excellence providers *

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
40. Implement Center for Excellence (COE) for Certain Surgical Procedures by January 1, 2026*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
42. Expand Centers of Excellence Program: to include colonoscopies, cataract surgery, and other routine procedures as defined by the Plan Design Committee no later than October 1st; Pilot COE in year one with incentives, then implement higher-tiered copays if the procedure is done at a non-COE provider, for each procedure, in year 2 and year 3; Specifically, in years one and two of the pilot program, members who utilize a COE network provider should obtain a Covered Service shall have no out of Pocket cost share*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
44. Direct Primary Care Medical Home Referrals - require referrals, where applicable, from SHBP DPCMH providers be directed only to providers included in the COE as establish under SHBP*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
46. If you answer "other" above, please expand upon the comments below or feel free to add additional comments on the Plan: Center of Excellence (COE) changes?
48. Prescription: GLP-1
50. End early refills for GLP-1 anti-obesity medications effective September 1, 2025*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
52. Implement a GLP-1 anti-obesity counseling and monitoring program*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
54. Implement three-tiered copay for GLP-1s for anti-obesity, effective January 1, 2026: brand preferred: $35/month, brand non preferred: $50/month*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
56. Reduce plan payment for Wegovy to $447.05 per month or no more than 90% of best negotiated pricing by utilizing rebates and other cost savings measures. Implement as of September 1, 2025*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
58. That State shall determine if the Diabetes/Insulin treatment category can be pulled out of medical claims and handled separately at a lower cost by a third-party vendor*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
60. Modify prescription drug co-pays across all plans in tandem with increased member cost share with GLP-1 Drugs, requiring all members & dependents prescribed a GLP-1 drug to participate in behavior modification/lifestyle management co-therapy *

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
62. Exclude coverage of GLP-1 drugs for weight loss only across all populations in tandem with increased member cost share with GLP-1 Drugs, requiring all members & dependents prescribed a GLP-1 drug to participate in behavior modification/lifestyle management co-therapy *

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
64. Across all populations limit access to GLP-1 drugs for weight loss to members with a BMI at or greater than 35 in tandem with increased member cost share with GLP-1 Drugs, requiring all members & dependents prescribed a GLP-1 drug to participate in behavior modification/lifestyle management co-therapy *

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
66. If you answer "other" above, please expand upon the comments below or feel free to add additional comments on the Prescription: GLP-1 changes?
68. Prescription
70. Identify high spend drugs to negotiate and purchase medications directly from manufacturer.*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
72. Evaluate all medications through the medical side of the program to determine savings if charged through prescription drug side. Require least costly method.*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
74. Implement mandatory step therapy program to require biosimilars first prior to any originator drugs; those already on specialty shall continue “as is”.*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
76. Institute cap on Medical Drug Prices (J drugs) at 120% of Average Sale Price*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
78. Implementation of two formulary advisors, one for general pharmaceutical that will make suggestions based on comparative effectiveness research who will make recommendations to the PDC on the drugs included in the formulary based on clinical efficacy, and one to assist with specialty medicines who will assist providers in finding the most effective drug for the members in their class. They shall be paid strictly on a PMPM or case basis.*

    1. Support Recommendations
    2. Oppose Recommendations
    3. Neutral
    4. Other (please describe below)
80. Audit all net prices for top 100 highest spend medications*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
82. Implement Clinical Effectiveness Based Formulary*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
84. Quarterly Review of FDA-approved medications*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
86. Reverse Auction of the Prescription Drug Contract*

    1. Support Recommendation
    2. Oppose Recommendation
    3. Neutral
    4. Other (please describe below)
88. If you answer "other" above, please expand upon the comments below or feel free to add additional comments on the Prescription changes?
90. Other Comments
92. Any other comments you would like to add:
94. Form Completed By:
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