Eligibility for coverage of some drugs cannot be determined from the information received with ordinary claims transactions. Therefore, there may be times when additional information is requested from your physician to clarify eligibility for coverage. Under these circumstances, the physician will need to submit a request for prior authorization or a request for quantities above the plan limit.
When pharmacists enter your prescriptions into their computer systems, they receive the message that a prior authorization is required. It is the pharmacist's responsibility to contact the prior authorization department and initiate the process. If you know that your medication is under the Dispensing Limit or Prior Authorization Program, you can ask your physician to contact your insurance company. Visit HorizonBlue.com a complete list of products and programs that are under the Pharmacy Utilization Management Programs.
Horizon BCBSNJ has a broad pharmacy network that consists of tens of thousands of pharmacies nationwide, conveniently allowing members to use pharmacies in other parts of the country. This extensive network includes many major chains and most independently owned stores. To find an in-network pharmacy, use our Pharmacy Finder tool or call the pharmacy member services number located on the back of your member ID card.
A formulary is a list of medications that are eligible for coverage under the Pharmacy Benefits Program. This list is created, reviewed, and continually updated by a group of physicians and pharmacists. The formulary contains a wide range of generic and brand-name preferred medications that have been approved by the U.S. Food and Drug Administration. Your doctor can use the formulary for your health care needs, while helping you maximize your prescription drug benefit. The formulary applies to medications that are dispensed in both retail and mail-order pharmacies.
The Horizon Pharmacy and Therapeutics Committee (P&T Committee) is an independent group of physicians and pharmacists that regularly reviews new and existing drugs and evaluates them based on clinical safety and efficacy. This committee makes decisions that determine the formulary status of medications.
A copay is the out-of-pocket amount a member has to pay the pharmacy. The member pays one copay per prescription. This fee is usually less than the actual price of the prescription and can vary based on the product and the member's benefit design. If the price of the prescription is less than the copay, then the member will pay the lower price. Usually, generic and preferred-brand products have lower copays.
A three-tier copay structure is a type of pharmacy benefit design offered by insurers. It is an effective cost-containment strategy that promotes cost-sharing and provides incentive for utilization of preferred products. The following is a typical three-tier copay structure: $5 for preferred generic products (tier 1), $15 for preferred-brand products (tier 2), and $30 for non-preferred products (tier 3).
The brand name is the trade name under which the product is advertised and sold. The drug is protected by patent, so only one manufacturer can produce it. Once a patent expires, other companies may manufacture a generic equivalent.
Generic drugs are drugs for which the patent has expired, allowing other manufacturers to produce and distribute the product under the chemical name. In order to be approved by the U.S. Food and Drug Administration (FDA), generics must show proven equivalency, safety, and effectiveness. Generics are eNational Accountsntially chemical copies of their brand-name counterparts. The color or shape may be different, but the active ingredients must be the same for both. An example of a generic medication is enalapril, which is the generic equivalent to Vasotec.
Generic drugs are the un-branded form of a prescription medication. They use the same active ingredients as brand name drugs and work the same way.
The FDA puts all generic drugs through a rigorous, multi-step process to ensure that they are the therapeutic equivalent of their brand name counterparts. That means that a generic drug can be substituted for a brand name drug, and it will produce the same clinical effect while meeting the same safety profile as the brand name drug.
You often won’t notice the difference between a generic drug and a brand name drug, other than its size, color or shape, which only differs due to trademark laws in the U.S. not allowing a generic drug to look exactly like other drugs already on the market.
The FDA ensures every generic drug is safe and effective before it goes to market. How?
- The generic drug must have the same active ingredients, have the same amount of active ingredients, deliver them in the same amount of time and be available in the same strength and dosage form as its brand name counterpart.
- The generic drug must be shown to work the same in the body, perform in the same manner and have the same risks and benefits as its brand name counterpart.
- The label of the generic drug must include the same information found on the packaging of its brand name counterpart.
- The generic drug must pass a review of both active and inactive ingredients.
- The manufacturing facility of the generic drug must pass rigorous inspection.
- The generic drug must be continuously monitored for quality control, even after it’s been approved.
Generic drugs cost less because their manufacturers don’t have to spend the hundreds of millions of dollars it takes to complete research and development on the new, original drug. The brand name drug manufacturer makes that investment, along with the millions of dollars needed to market and advertise the new drug. Therefore, it costs the generic manufacturer less to develop the same drug—and the savings are passed on to you.
Research shows that you can save between 30% to 80% when you fill your prescriptions with generic drugs instead of brand name drugs. But the exact number depends on your prescription drug coverage.
Want to get an idea of what you can save based on your pharmacy benefit plan and information? Register or sign in to our secure member web portal to create a savings report and get access to other helpful pharmacy tools.
A preferred drug is a medication that has been clinically reviewed and approved by a group of physicians and pharmacists. The medication has been included based on its proven clinical and cost effectiveness.
A non-preferred drug is a medication that has been reviewed by the same group of physicians and pharmacists, but has been determined to have an alternative drug available that is clinically equivalent. Drugs that are newly approved by the FDA are initially designated as non-preferred. These drugs are not reviewed until they have been available for six months. The designation of a medication may change over time, as more clinical information becomes available.
Some of the benefits of our mail-order service, administered by AllianceRx Walgreens Prime, include: (1) easy, in-home delivery; (2) ability to refill prescriptions and check the status of your order online.
To speak with a AllianceRx Walgreens Prime representative, call 1-888-844-3828.
If you have mail service as part of your pharmacy coverage and take medications on an ongoing or regular basis, you may benefit from AllianceRx Walgreens Prime®. This helpful service can help you save time and money by having prescriptions delivered right to you. To learn more about the program and how to get started, visit our Prescriptions by Mail page.