Prime Therapeutics (Prime) is your pharmacy benefit manager. That means Prime works on behalf of Horizon to manage your Part D prescription benefits. Prime will help you safely manage your medicine. A full list of medicine covered by Horizon NJ TotalCare (HMO D-SNP) is available on MyPrime.com.
How to Use Your Formulary
Sometimes, medicine may have restrictions or need approvals before your pharmacy can fill the prescription. For example:
- Prior authorization: Your doctor may need to get approval from Prime before you can fill the prescription.
- Quantity limit: You might only be able to fill a certain amount of your prescription in a certain number of days.
- Step therapy: You may need to try an alternate medicine first, such as trying the generic version of a drug before the brand name version.
To find out if your medicine needs approval or has restrictions:
- Go to MyPrime.com. On the top bar, click Medicines and select Find medicines in the dropdown menu.
- Click Continue without sign in. Select Horizon BCBSNJ as your health plan. Select Yes for Medicare Part D member, select 2023 for the plan year, select Horizon NJ TotalCare (HMO D-SNP) from the list and click Continue.
- Type the name of your medicine or condition into the search bar under “Add a medicine.” Select your medicine dosage and how much you take per day or month. If your drug has requirements such as Quantity Limit, Step Therapy or Prior Authorization, you will see “ This medicine has additional requirements.”
- If your drug requires a formulary exception, you will see “Not on drug list, Non-formulary.”
You or your doctor can submit a request for prior authorization, step therapy, formulary exception or quantity limit by:
- Phone – 1-855-457-1346 (TTY 711)
- Fax – 1-800-693-6703
- Mail – Prime Therapeutics LLC, Attn: Medicare Appeals Department, 2900 Ames Crossing Road, Eagan, MN 55121
- Online – MyPrime.com
All request forms are available online at MyPrime.com. You do not need to submit a form to make a request.
All available medicine is in the List of Covered Drugs (Formulary) for Horizon NJ TotalCare (HMO D-SNP).
You have options for how to fill your prescriptions:
- Pharmacy network: A group of pharmacies that have a contract with your health plan. Search for pharmacies on MyPrime.com.
- Retail pharmacy: A community pharmacy where you can order and pick up prescription medicine, such as a drug store or grocery store.
- Specialty pharmacy: A type of pharmacy that dispenses specialty medicine to treat complex conditions like cancer and autoimmune diseases. These pharmacies also provide in-depth patient support from a team of nurses and pharmacists.
- Mail-order pharmacy: A convenient service that delivers your medicine through the mail. Horizon offers mail-order services through Express Scripts Pharmacy, AllianceRx Walgreens Prime and PillPack by Amazon.
First, your doctor or nurse practitioner will give you a prescription for your medicine in one of three ways:
- Physical copy: a certified prescription that is written or printed that you to bring to your pharmacy.
- Electronic copy: the prescription will be sent directly to your pharmacy through an online portal.
- Verbal order: your health care provider will call your prescription in to the pharmacy.
Once the order is sent to the pharmacy:
- The pharmacist will check the inventory to see if they have enough or if they need to order it.
- Pharmacy staff will prepare the medicine, such as counting pills or preparing a mixture.
- The pharmacist will check your order to make sure that it has been prepared correctly and is safe to take with your other prescription medicine.
- The pharmacy will call you or send a text message when your prescription is ready, if you have opted in to those alerts.
What Are Refills?
The prescription you get from your doctor will include the number of refills allowed. This number is the amount of times you can get another supply of that medicine without having to visit your doctor again. Once that number runs out, you may need to see your doctor for more refills. Certain medicines, like opioids, cannot be refilled. You may need to see your doctor for a new prescription, or your doctor may give you multiple prescriptions so you don’t need another office visit.
If you subscribe to automatic refills, your medicine will be filled automatically every month by your pharmacy. You do not have to request a refill.
A 90-day supply is a prescription that has enough medicine to last for 90 days, or three months. A 90-day supply of your medicine reduces the number of times you have to visit your pharmacy to pick up your medicine. Instead of making a trip to the pharmacy every month, you can make a trip every three months or get your medicine in the mail.
Here are some things to remember:
- Ask your doctor for a 90-day supply when they write your prescription. If you already have your prescription, ask your pharmacist to call your doctor to change it to 90 days.
- You can also ask your doctor to include refills on your prescription.
- Ask your pharmacist to enroll in automatic refills.
- Prescriptions expire after 12 months. Even if you have refills left, you will need a new prescription after 12 months.
Insurance Coverage: Words to Know
You may see these words when reviewing your plan information.
Claim: your doctor or pharmacy requests payment from the health insurance company when you get items or services.
Formulary: also called a drug list, this is a list of medicine that is covered by your insurance.
Generic drug: a prescription medicine that is the same dose as a brand name and has the same strength, method, safety, quality and intended use as a brand name. Generics usually cost less than brand name medicines.
Prior authorization: your doctor must ask permission from Horizon before you can receive the medicine. It gives us a chance to review how necessary a medical treatment or medicine may be for treating a medical condition.
Step therapy: you must try one or more similar, lower-cost medicine to treat a condition before Horizon will pay for the requested medicine. For example, trying a generic version before a brand name.
Drug Benefit Comparison
Over-the-counter (OTC) benefits vs. standard Medicaid-covered drugs and items.
|Member Feature||Over-the-Counter (OTC) Benefit Catalog||Horizon EXTRA Benefits Card||Medicaid Wrap Drug Coverage|
|Benefit||Every three months you will receive a $270 credit (up to $1,080 yearly) that will allow you to purchase personal health items from our OTC Benefit Catalog.||Every three (3) months you will receive a $400 credit (up to $1,600 yearly) on your Horizon EXTRA Benefits Card that will allow you to purchase personal health items from our participating retailers.||Prescription and over-the-counter drugs covered at no cost to you by the Medicaid portion of your plan.|
|What's Included||Review the OTC Benefit Catalog for complete list of over 250 over-the-counter items.||Go to HorizonExtraBenefits.com for a complete list of over 900,000 eligible items.||Review the List of Covered Drugs (Formulary) for a complete list of prescriptions and over-the-counter items.|
|Prescription Required||No||No||Yes, from your provider|
|How to Order||
For more information on your OTC products and prescription drug benefits, call Member Services at 1-800-543-5656 (TTY 711), 24 hours a day, seven days a week.