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Three-Tier Benefits Overview

Horizon BCBS is committed to providing members with access to safe and effective medications. We offer a three-tier prescription drug benefit which is designed to allow members to choose drugs that best meet their medical needs. This benefit structure encourages patients and physicians to discuss possible treatment options and to choose the most appropriate and cost-effective care.

Covered medications are categorized into one of the three tiers described below:

Decisions to place brand medications into either Preferred or Non-Preferred status are made by the Pharmacy and Therapeutics Committee (P&T Committee) of Horizon BCBS. The P&T Committee is a group of physicians, clinicians and pharmacists that serve as external medical consultants. Its primary purpose is to maintain a consistent and therapeutically appropriate approach to the administration of the drug benefit, including the development of the formulary, prescribing guidelines and educational materials related to drugs and drug use.

The priority consideration for allocation of drugs into preferred and non-preferred placement is a quality review based on clinical efficacy and safety margins of the drug. Other considerations, such as second line therapies, utilization metrics, brands for which there exists in that class of drugs commonly used and safe generics, are additional factors. The formulary is set annually with changes quarterly as required.

Prime Therapeutics LLC supports Horizon Blue Cross Blue Shield of New Jersey in the administration of prescription drug benefits. Prime Therapeutics LLC is independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross Blue Shield Association.