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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. 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: $5 for preferred generic products (tier 1), $15 for preferred-brand
products (tier 2), and $30 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 Three-Tier 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 U.S. Food and Drug Administration (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 enalapril, which is
the generic equivalent to Vasotec®.
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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
Caremark's Web site at www.caremark.com
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 Caremark'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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