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Pharmacy Guidelines

The following Pharmaceutical Utilization Management (UM) Programs help ensure access to medically necessary and appropriate, cost-effective drug therapy. Our Pharmaceutical Utilization Management(UM) Programs help ensure access to medically necessary and appropriate, cost-effective drug therapy.

Medical Necessity Determination

All medications are subject to Medical Necessity review. We focus our reviews on those drugs that have a high potential for inappropriate use, high-cost medications, those that have narrowly defined FDA-approved indications and medications that have a significant interaction risk if taken with other agents.

Medical Necessity criteria and guidelines are established and approved by physicians and pharmacists. These external oversight committees assure that our Medical Necessity criteria and guidelines reflect community prescribing standards for the appropriate medication prescribed for members.

Medical Necessity determination consists of three programs: Drug Dispensing Limitations, Drug Utilization Review (DUR) and Prior Authorization.

Tier Exceptions

Horizon Blue Cross Blue Shield of New Jersey has tiered copayment structures in its prescription drug benefits. A member’s copayment will vary depending upon how the prescription drug is classified by the Pharmacy and Therapeutics Committee and in which tier the drug is placed within the prescription drug formulary; that is whether it is considered a Preferred generic drug, Preferred brand name drug or non-Preferred drug. A member or his or her doctor may request that a non-Preferred drug be covered at the Preferred drug copayment level in the event that the Preferred drug or generic equivalent has been tiered and there is documented ineffectiveness or intolerance. Please call our pharmacy benefits manager, Prime Therapeutics LLC, to initiate this process and request an exception at 1-888-214-1784.

Drug Dispensing Limitations

Certain prescription medications have specific dispensing limitations for quantity, age, gender and maximum dose. To arrive at these quantity or safely limits, Horizon Blue Cross Blue Shield of New Jersey follows recommendations by the U.S. Food and Drug Administration (FDA), coupled with our analysis of prescription dispensing trends and standard clinical guidelines. These dispensing limitations are drug specific and are designed to provide a safe and effective amount of medication to the member. Included in the drug dispensing limit program is the age and gender limitations, which are safety edits based on FDA-approved product labeling.

To view our formulary for age and gender limit and/or dispensing limit requirements, click here. Please note this list is subject to change and will be updated periodically.

If the drug you’re prescribing has a drug dispensing limit, and/or age and gender limit, please call Prime Therapeutics LLC at 1-888-214-1784 to initiate the process for drug dispensing limit override.

Specialty pharmaceuticals are a class of prescription drugs that are typically produced through biotechnology (sometimes known as biologics) and require special patient monitoring and handling. Specialty pharmaceuticals also require unique education prior to use

Drug Utilization Review (DUR)

Since a member can be seen by different doctors and obtain medication through a variety of pharmacies, DURs help prevent drug safety issues and identify any gaps in care. Our online claims processing computer system allows immediate review and verification of eligibility, prescription drug coverage, drug-drug interactions, and restrictions. We are also able to integrate pharmacy and medical claims to thoroughly identify any gaps in care or safety concerns. We provide written reports to member’s treating physicians to fully inform them of any issues that have been identified.

Prior Authorization/Medical Necessity Determination (PA/MND)

For the medications that are subject to PA and/or MND criteria, please download our Prior Authorization List PDF Please note, the lists are subject to change and will be periodically updated.

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 medications that are medically necessary and appropriate are approved for coverage. PA/MND also encourages appropriate utilization 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 for patients.

Specific guidelines and criteria for medical necessity, developed and approved by physicians and pharmacists, must be met before certain drugs are approved and covered under a patient’s prescription drug benefits. The Horizon BCBSNJ Pharmacy and Therapeutics Committee comprises practicing physicians, pharmacists and Horizon BCBSNJ health care professionals. The Committee establishes PA/MND criteria after evaluating the most current published, peer-reviewed medical literature, physicians and health care professionals’ opinions practicing in the relevant clinical areas, specialty society recommendations and FDA-approved labeling information. Only after PA/MND criteria are met can a prescribed drug be authorized and covered. Copayment amounts are determined by prescription drug benefits. If medical circumstances do not meet the PA/MND requirements, and PA/MND is denied, your patient may still purchase the drug, but his/her health plan will not reimburse the cost.

The PA and MND programs may also include programs to promote generic use.

Some plans may include enhanced utilization management (UM) programs and PA/MND requirements. If a patient has not already tried a generic equivalent where available, and there is not a medical reason for not trying a generic, he/she will be required to try a generic drug first before a brand name equivalent would be considered medically necessary.

This also pertains to certain drug categories where multiple generics are available, and patients may be expected to try a generic drug first before filling a prescription for a non-preferred brand name drug in the same therapeutic category. This UM program encourages the use of lower-cost generics, when available, as an alternative to brand name drugs within the same class.

During the course of a patient’s treatment, there may be circumstances where a non-Preferred brand name drug should be dispensed, even though a generic equivalent or generic alternative is available.

When the pharmacist enters the requested prescription into the point-of-sale system, they are advised when PA/MND is required before that particular brand name drug may be covered and dispensed. If the prescription history shows authorization was received or a recent trial with a generic equivalent or generic alternative, then no additional information is required and the brand name prescription drug can be filled.

If the pharmacy system history does not show an authorization or a recent trial of a generic drug equivalent or generic alternative, the claim for the brand name drug may not be dispensed for the full prescription and the pharmacist will advise your patient. If PA/MND is not sought or is denied, your patient can purchase the brand name drug without using his/her prescription drug benefits. If a generic can be taken, then PA/MND is not required.

If you feel that a non-Preferred drug is medically necessary due to ineffectiveness or intolerance to a previously tried generic equivalent, PA/MND can be requested for the non-Preferred drug. Such PA/MND requests will be reviewed promptly by a qualified peer reviewer/physician through the plan’s PA/MND process.

Administrative Policies

Medical Necessity Determination Policy For Prescription Drugs (PDF)

This policy sets forth the procedure Horizon BCBSNJ uses in making a medical necessity determination for prescription drugs or categories of prescription drugs. The Medical Necessity Determination drug list consists of three programs: Drug Dispensing Limitations, Drug Utilization Reviews (DURs) and Prior Authorization. All medications are subject to Medical Necessity review. Horizon BCBSNJ focuses reviews on drugs that have a high potential for inappropriate use, are expensive, have narrowly defined FDA-approved indications and have a significant interaction risk if taken with other agents. The Medical Necessity Determination process can be initiated in three ways: point of service, prior to point of service and after drug is dispensed.

Pharmaceutical Prior Authorization Policy (PDF)

This policy sets forth the procedure for the Pharmaceutical Prior Authorization process. Prior Authorization ensures appropriate utilization of certain drugs, promotes treatment or step-therapy protocols, actively manages drugs with serious side effects, and positively influences the process of managing drug costs. The Pharmaceutical Prior Authorization process can be initiated in three ways: point of service, prior to point of service and after drug is dispensed.

Prescription Drug Tier Exceptions Approval Policy (PDF)

The purpose of this policy is to describe the process of obtaining coverage of a non-Preferred drug at the Preferred level of coverage—if the member has prescription drug benefits with a Drug Formulary based tier structure. The Preferred drug list is a list of prescription medications that contains Preferred generics and Preferred brand-name medications. This Preferred drug list is created, reviewed and continually updated by an independent group of physicians and pharmacists who sit on the Horizon Blue Cross Blue Shield of New Jersey Pharmacy and Therapeutic Committee.

Orally Administered Cancer Medication Coverage Law Effective as of July 15, 2012

New Jersey Public Law, 2011, C. 188, requires health insurance carriers to cover cancer medications taken orally “on a basis no less favorable than” intravenous or injected cancer medications.

Coverage for prescribed orally administered cancer medications is not to be subject to any prior authorizations, dollar limitations, deductibles, copayments or coinsurance that does not apply to intravenously administered or injected cancer medications.

Orally administered cancer drugs are prescription drugs that: (a) are used to slow or kill the growth of cancerous cells, and (b) are given orally (by mouth).

Such drugs do not include those that:

  • Maintain red or white cell counts.
  • Treat nausea.
  • Support the cancer prescription drugs.

Affected Insurance Plans

This law, effective as of July 15, 2012, applies to those insured plans that are issued or renewed in the state of New Jersey on or after that date.
The law also applies to the State Health Benefits Program (SHBP) and effective for their members as of July 15, 2012.

Find answers to common questions about the Orally Administered Cancer Medication Coverage mandate.

Downloadable Information

Dedicated Claims Form

To help expedite your patients’ claims for oral medication(s), Horizon BCBSNJ created a dedicated claims form. The link above takes you to a downloadable claims form, with an instruction sheet. Your patients will need to send in their patient prescription information leaflet and cash register receipt each time for their claims to be considered for reimbursement.

List of Approved Oral Anticancer Medications

For a comprehensive list of the medications affected by this new law.

To view our formulary for age and gender limit and/or dispensing limit requirements, click here.