N.J. Admin. Code § Tit. 11, ch. 24, subch. 18, app APPENDIX
Current through Register Vol. 56, No. 24, December 18, 2024
Actuarial Justification of Benefit Differentials
Formulary Drug Benefit
| Use | Non | |
| Percent | Formulary | Formulary |
| Number of Scripts per member per year | ||
| Brand | ||
| Generic | ||
| Composite | ||
| Ingredients cost including dispensing fees | ||
| Brand | ||
| Generic | ||
| Composite | ||
| Copays/Coinsurance/Deductible/OOP | ||
| Brand copay | ||
| Generic copay | ||
| Coinsurance | ||
| Deductible | ||
| Out-of-pocket limit | ||
| (excl. ded) | ||
| Calculation | ||
| (1) Starting claim cost PMPM | ||
| - | (2) Adjustment for | |
| brand copay | ||
| - | (3) Adjustment for | |
| generic copay | ||
| = | (4) Adjustment claim cost | |
| (5) Value of deductible | ||
| x | (6) Impact of 3x family | |
| deductible | ||
| = | (7) Adjusted value | |
| of deductible | ||
| (4)-(7) | (8) Adjusted claim cost | |
| x | (9) Coinsurance | |
| = | (10) Adjusted claim cost | |
| + | (11) Impact of | |
| out-of-pocket limit | ||
| = | (12) Adjusted claim cost | |
| (13) Formulary discount | ||
| (12) x (1-(13). | (14) Net claim cost | |
| (14)/(1) | (15) Benefit ratio | |
| (15 in)-(15 oon) | (16) Benefit differential | |
N.J. Admin. Code Tit. 11, ch. 24, subch. 18, app APPENDIX