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On February 15, 2017, New Jersey Governor Christie signed P.L. 2017, Chapter 28, the New Jersey Substance Use Disorder Law, which sets certain coverage requirements for the treatment of substance use disorders and regulates prescriptions of opioid drugs. This law:

  • Requires the State Health Benefits Program (SHBP)/School Employees’ Health Benefits Program (SEHBP) to cover inpatient and outpatient treatment of substance use disorders at in-network facilities
  • Puts certain restrictions on prior authorization or utilization management for the first 180 days per plan year of medically necessary inpatient and outpatient treatment of substance use disorders
  • Places certain restrictions on prescribed opioids, such as a five-day supply limit on initial prescriptions

Effective May 16, 2017, SHBP and SEHBP members will be covered under the mandate.

The following is a high-level overview of substance use disorder coverage implications:

  • Horizon BCBSNJ must be notified of a member’s admission and the initial treatment plan within 48 hours of the member’s admission or initiation of treatment.
  • Benefits for the first 28 days of treatment (inpatient stay, intensive outpatient or partial hospitalization services) during each plan year must be provided without any prior authorization, retrospective review or concurrent review of medical necessity.
  • Covered persons are entitled to 28 days of inpatient care during a plan year and a separate 28 days of intensive outpatient and partial hospitalization care per plan year.
  • Benefits for days 29 and up to day 180 of inpatient care can be subject to concurrent review. A request for approval of inpatient care beyond the first 28 days must be submitted for concurrent review before the expiration of the initial 28-day period.
  • Benefits for days 29 and up to day 180 of intensive outpatient or partial hospitalization services during each plan year cannot be subject to concurrent review.
  • After the first 180 days per plan year, Horizon BCBSNJ can make necessity determinations, prior authorization or retrospective review and other utilization management requirements. 
  • Except in the case of an in-network exception, a person who voluntarily uses an out-of-network provider will not be entitled to the protections of the law with respect to those out-of-network services.

If you have questions about substance use disorder treatment, please call Horizon Behavioral Health at 1-800-991-5579.

The following is a high-level overview of pharmacy coverage implications:

  • Benefits for outpatient prescription drugs for substance use disorder must be provided when determined to be medically necessary by the member’s physician, psychologist or psychiatrist without any prior authorization or other prospective utilization management requirements. 
  • Pursuant to emergency rules, the restriction to five-day supplies of initial opioid prescriptions for acute pain is effective March 1, 2017 for all members who receive an opioid prescription from a New Jersey prescriber.
    • “Acute pain” means pain, whether resulting from disease, accidental or intentional trauma, or other cause, that the practitioner reasonably expects to last only a short period of time.
    • “Acute pain” does not include chronic pain, pain being treated as part of cancer care, hospice or other end-of-life care, or pain being treated as part of palliative care. 
  • Effective May 16, 2017, members may pay a cost share that is based on the amount prescribed. Note: While members with Medicare Part D prescription coverage may receive an initial five-day fill, the proration of cost share does not apply.
    • Members may pay a cost share that is prorated when they receive their initial prescription for five days of opioids.
    • A subsequent prescription for the same opioid within 30 days of the initial
      five-day fill may also be prorated if less than a 30-day supply.

If you have a question about your pharmacy coverage, please call your pharmacy benefits administrator at the number on the back of your prescription ID card.