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FAQs
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What is a formulary?
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 (FDA).
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.
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What is a copay?
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.
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What is a three-tier copay?
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: $10 for preferred
generic products (tier 1), $25 for preferred brand products (tier 2), and
$50 for non-preferred products (tier 3).
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How does the formulary work with the three-tier copay?
The three-tier copay benefit works as follows: Tier 1 covers preferred generic products; Tier 2 covers preferred brand products; Tier 3 covers non-preferred brand and generic products. Under the three-tier copay benefit, all of the products on the formulary are covered. You will have to pay a higher copay 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. For more information regarding three-tier benefit design, click on 3-Tier Benefit Overview.
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What is the difference between brand-name and generic-name drugs?
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 FDA, generics must show proven equivalency, safety, and effectiveness. Generics are essentially 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 simvastatin, which is the generic equivalent to Zocor®.
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What is the difference between a preferred drug and a non-preferred drug?
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.
Who are the physicians and pharmacists who manage the formulary?
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.
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How do I use my mail-order service option?
If you have mail service as part of your pharmacy coverage and take
medications on an ongoing or regular basis, you may benefit from
Caremark's mail service pharmacy. Your physician may call in your new
prescription to Caremark. Or, you can just fill out the mail service
order form and send it in with your prescription(s). Visit Pharmacy Service at
www.horizonblue.com/pharmacy to learn more.
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What are the benefits of mail-order service?
Some of the benefits of mail-order service include: (1) easy, in-home
delivery; (2) use of Horizon's Web site to refill prescriptions and check
the status of your order.
To speak with a Caremark Member Services representative, call
1-866-881-5603.
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If I am out of my normal service area and need a prescription,
what should I do?
Horizon BCBSNJ has a broad pharmacy network that consists of more than 62,000
pharmacies nationwide,
conveniently allowing members to use pharmacies in other parts of the country.
This extensive network includes many major chains, such as CVS, Eckerd,
Drug Fair, Pathmark, Rite Aid, ShopRite, Target, Walgreens, and Wal-Mart,
as well as most independently owned stores. Pharmacy verification is available
by contacting Caremark's Member Services at 1-866-881-5603.
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What are the Pharmacy Utilization Management Programs, and why do certain drugs require this?
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.
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How can I obtain a medication that is under one of the Pharmacy Utilization Management Programs?
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. For a complete list of products and programs
that are under the Pharmacy Utilization Management Programs, please click on
Pharmacy Utilization Management Programs.
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