On September 24, 2025, the NJ SHBP Plan Design Committee (PDC) met and approved several changes to the prescription drug plans for the State Health Benefits Program – Local Government (SHBP-LG).
Key Updates
The following changes apply to all SHBP-LG prescription plans (except the HD High Plan which was not referenced in the resolution) and only to active employees. There were no changes to the early retirees or Medicare-eligible retirees.
Effective November 1, 2025, non-diabetic GLP-1 drugs prescribed for weight loss will carry a $45 copay per 30-day supply until the State implements a lifestyle management program. Once the program is active, members who participate will continue paying the $45 copay, while those who do not participate in a lifestyle management program will see their copay rise to $125 per 30-day supply.
Beginning Plan Year 2026, the SHBP-LG will introduce the following copay structure:
● Generic drugs: $10 retail (per 30-day supply) / $10 mail order (90-day supply)
● Preferred brand drugs: $20 retail (per 30-day supply) / $50 mail order (90-day supply)
● Non-preferred brand drugs: $75 retail (per 30-day supply) / $150 mail order (90-day supply)
● Specialty drugs: $75 (available through mail order only, up to a 30-day supply)
In addition, mail order will become mandatory for all maintenance drugs. The resolution also sets new out-of-pocket maximums for prescription drug benefits: $2,120 for individuals and $4,240 for families. All other prescription benefits remain unchanged—such as mandatory generic, mandatory mail order for specialty drugs, step therapy, and an exclusionary formulary.
As of now, the above plan changes do not come with any rate reduction off the double-digit premium increases for 2026 which were approved in early September.
Benecard will continue to closely monitor this ongoing situation and keep you updated on any further developments or communications related to the NJ SHBP-LG. In the meantime, if you have any questions on this topic, please email us at talktous@benecard.com.
Sources:
