Your plan may have prescription drug coverage administered by Prime Therapeutics LLC (Prime). Look at your member ID card for the Prime logo or read your SPD or Benefit Booklet to find out if this is part of your benefits.
If you have pharmacy benefits through Horizon BCBSNJ, we have a quality process for select prescription drugs or prescription drug categories that have the potential for misuse, abuse and adverse effects. These prescription drugs are commonly used for purposes other than those approved by the Food and Drug Administration (FDA). Through our prior authorization process, we check for medical necessity and appropriateness based on FDA-approved use, peer review, clinical literature and national standards.
Eligibility for coverage of some drugs cannot be determined from the claims submitted. We may need additional information from your doctor. In these cases, your doctor must submit a request for prior authorization or a request for quantities above the plan limit.
We have a list of Preferred and non-Preferred prescription drugs. This list is maintained by our Pharmacy and Therapeutics (P&T) Committee. This Committee regularly reviews new and existing drugs based on criteria such as safety and how well they work.
When your pharmacist enters your prescription into his/her computer system, a prior authorization message may appear. You, your pharmacist or doctor must call our pharmacy benefits manager at the Pharmacy Member Services number on the back of your member ID card to request a prior authorization.
It is important that you or your doctor begin a review as soon as possible to help eliminate any delay in receiving your medication from the pharmacy. If prior authorization has not been received, you may be limited to a 96-hour supply while waiting for the prior authorization process to be completed.
Online Pharmacy Services
- Look up prescription drug coverage and pricing.
- Learn about generic drugs.
- Set up mail order service for your prescription medications.
- Find prescription drug information.
- Find a nearby pharmacy.
Specialty Pharmacy Services
Drugs that require special monitoring, administration or handling are called specialty drugs. We have contracts with pharmacies that specialize in these types of drugs. These pharmacies will:
- Give you information to help you learn about your medicine.
- Help with your pharmacy claims.
If you take a specialty drug, your doctor will work with us to determine medical necessity. For more information about your prescription drug benefits or specialty pharmaceuticals, call Pharmacy Member Services at 1-800-370-5088.