A formulary is a list of medications eligible for coverage under the pharmacy benefits program. This list is created, reviewed and continually updated by a group of physicians. The formulary contains a wide range of generic and brand-name preferred medications that have been approved by the FDA. A member’s doctor can use the formulary for their health care needs, while helping them maximize their prescription drug benefit. The formulary applies to medications that are dispensed in both retail and mail-order pharmacies.
The Horizon Pharmacy and Therapeutics Committee is an independent group of physicians 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.
Under the three-tier copayment benefit, all of the products on the formulary are covered. Members will have to pay a higher copayment for non-preferred products. Decisions to determine whether a medication is preferred or non-preferred are made by an independent group of physicians and pharmacists.
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.
Members 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.
Members can learn more and see how much they could be saving on our Generic Drugs page.
Often two brand name drugs help treat the same problem, but one has been shown to be more cost- or medically effective than the other. That drug becomes a preferred drug, and the other becomes a non-preferred drug. Decisions to determine whether a medication is preferred or non-preferred are made by an independent group of physicians.
If a member has mail service as part of his or her pharmacy coverage and takes medicine on an ongoing or regular basis, the member may benefit from PrimeMail®. This helpful service can help members save time and money by having prescriptions delivered right to them. To learn more about the program and how to get started, visit our Prescriptions by Mail page.
Setting up the prescriptions by mail service can have a number of benefits, depending on a member’s prescription or health benefit plan. In general, the service provides easy, in-home delivery and lets members refill prescriptions and check the status of their order through Member Online Services.
With some plans, receiving prescriptions by mail also features a lower copayment. Members should call the pharmacy member services number located on the back of their member ID card for more information on their plan.
Certain drugs require Prior Authorization or Medical Necessity Determination (PA/MND) before coverage is approved. The PA/MND process is designed to assure that only prescription drugs that are medically necessary and appropriate are approved for coverage. PA/MND also encourages appropriate use of certain prescription drugs, promotes generally accepted treatment protocols, actively monitors prescription drug use that may have serious side effects and helps keep the cost of prescription drug therapy affordable.
To learn more and see what they can do if their medication requires PA/MND, members should visit our Prior Authorization page.
Drug dispensing limitations (also know as quantity limits or QLs) and Drug Utilization Review (DUR) are part of the Prior Authorization or Medical Necessity Determination (PA/MND) process. Learn More
Q. What if a member goes to a pharmacy that is not contracted with Horizon BCBSNJ’s medical network?
If a member receives a vaccination from a pharmacy that does not participate with Horizon BCBSNJ’s medical network, the members will pay more and can submit an out-of-network medical claim form to Horizon BCBSNJ seeking reimbursement for the expense. Claim forms are available at HorizonBlue.com/forms.