Division of Pensions and Benefits, SHBP/SEHBP COVID-19 Response

Division of Pensions and Benefits, SHBP/SEHBP COVID-19 Response The Division of Pensions and Benefits, together with our vendor partners Aetna, Horizon BCBSNJ, and OptumRx, are taking action to ensure that State Health Benefits (SHBP) and School Employees Health Benefits (SEHBP) members have the support and resources they need during the COVID-19 situation, which remains dynamic and evolving. The Division of Pension and Benefits has advised the Third Party Administrator for the SHBP and SEHBP that, effective immediately, all cost sharing for emergency room (in or out of network hospitals), urgent care (in network), or provider office visits (in network) associated with medically necessary testing for COVID-19 are to be waived. The Third Party Administrator has been directed to inform contracted providers about the waiving of cost sharing. The Pharmacy Benefit Manager has been directed, effective immediately, to lessen restrictions on early refill for Rx on maintenance medications so that individuals have access to medically necessary medications without waiting until the end of prescription cycle.

Questions about Testing Coverage through Horizon BCBS

Q. Should I get tested if I don’t have symptoms?

Please note that testing asymptomatic individuals is not medically indicated and is against the current advice of the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO). CDC recommends voluntary home quarantine for those who have traveled to/from countries where COVID-19 has spread or who have been exposed to individuals with the virus.

Q. If I do get tested for COVID-19, will I pay copayment or co-insurance?

All cost sharing for emergency room (in or out of network hospitals), urgent care (in network), or provider office visits (in network) associated with medically necessary evaluation and testing for COVID-19 are to be waived. Horizon BCBS will instruct providers that they should bill all evaluation and testing services related to COVID-19 to ICD10 Code Z20.828 and instruct all providers that no cost sharing is to be collected from SHBP/SEHBP members.

Q. Will treatment or a COVID-19 vaccine be covered by insurance?

At this time, there is no specific antiviral treatment or vaccine for COVID-19. Members should call their doctors to ask about care to help relieve symptoms as they would for other viral respiratory infections. Horizon BCBSNJ will continue to cover medically necessary health care costs to treat infectious diseases, including COVID-19, based on the terms of the SHBP/SEHBP.

Q. Are telemedicine services covered to ensure access to care while reducing the opportunities for disease transmission?

SHBP/SEHBP members will have no cost, 24/7 access to licensed nurses who can assess and assist members with symptoms that are consistent with suspected COVID-19 infection available through the Horizon Blue app, the secure member portal, or by phone at 1-888-624-3096.

Q. Will Horizon BCBSNJ waive prior authorization requirements for treatment of COVID-19?

The Division will ensure that Horizon will:

 Waive prior authorizations for a visit to a primary care physician, urgent care center, or emergency room for evaluation of upper respiratory symptoms, fever, shortness of breath or other conditions that may represent COVID-19.

 Waive prior authorizations for diagnostic tests and for covered services that are medically necessary and consistent with CDC guidance if diagnosed with COVID-19.

 Waive prior authorization for lab studies or diagnostic testing required during an ER evaluation or inpatient hospital stay.

Questions about Testing Coverage through Aetna Medicare Advantage

Q. What resources are available to Aetna Medicare Advantage Members?

Effective immediately, SEHBP and SHBP Aetna Medicare Advantage members will have access to the following resources: Aetna will provide all diagnostic testing related to COVID-19 at no cost to you. This policy will cover the test kit for patients who meet CDC guidelines for testing, which can be done in any approved laboratory location. Aetna will waive the member costs, if any, associated with diagnostic testing at any authorized location for SEHBP and SHBP Medicare members. Through Aetna's Healing Better program, members who are diagnosed with COVID-19 will receive a care package containing CVS over-the-counter medications to help relieve symptoms. The package will also include personal and household cleaning supplies to help keep others in the home protected from potential exposure. Through existing care management programs, Aetna will proactively reach out to members most at-risk for COVID-19. Care managers will walk members through what they can do to protect themselves, where to get information on the virus, and where to go to get tested.

Questions about Prescriptions through OptumRx

Q. Can I fill my prescriptions early to avoid running out?

To ensure that our members with prescription drug coverage through the SHBP/SEHBP continue to have uninterrupted access to medications, the “Refill Too Soon” (RTS) restriction on prescriptions obtained at retail pharmacies will be suspended through March 31st. Typically, prescriptions need to reach a threshold of remaining days’ supply before a refill can be dispensed again. Suspension of this restriction will enable members and patients to refill prescriptions before reaching this threshold and will ensure sufficient quantities of medication remain available to them.

The Division will continue to rigorously monitor the COVID-19 situation and determine what additional actions beyond March 31st might be necessary.

Additional Resources: We encourage you to get the latest coronavirus news from credible information sources listed below.

 World Health Organization

 Centers for Disease Control and Prevention (CDC)

 National Institutes of Health

 The New Jersey Department of Health or call the 24-hour public hotline at 1-800-222-1222


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