3-Tier Benefit Overview

Horizon BCBSNJ is committed to providing members with access to safe and effective medications. We offer a three-tier prescription drug benefit which is designed to allow members to choose drugs that best meet their medical needs. This benefit structure encourages patients and physicians to discuss possible treatment options and to choose the most appropriate and cost-effective care.

Covered medications are categorized into one of the three tiers described below:

• Tier One: Preferred Generic Drugs (lowest copay)
  Approved by the U.S. Food and Drug Administration, generic drugs contain the same active ingredients as brand-name medications. Generics are chemically and therapeutically equivalent to brand drugs, but are available at a lower price.
   
• Tier Two: Preferred Brand Drugs (middle copay)
  These brand-name drugs have been identified as the most therapeutically safe and effective options for treatment of most medical conditions. These drugs do not have less-costly generic equivalents because they are sold under a trademarked name.
   
• Tier Three: Non-Preferred Brand and Generic Drugs (highest copay)
  These products often have either a generic equivalent or a preferred-brand drug alternative.
   

Decisions to place brand medications into either Preferred or Non-Preferred status are made by the Pharmacy and Therapeutics Committee (P&T Committee) of Horizon BCBSNJ. The P&T Committee is a group of physicians, clinicians, and pharmacists that serve as external medical consultants. Its primary purpose is to maintain a consistent and therapeutically appropriate approach to the administration of the drug benefit, including the development of the formulary, prescribing guidelines, and educational materials related to drugs and drug use.

The priority consideration for allocation of drugs into preferred and non-preferred placement is a quality review based on clinical efficacy and safety margins of the drug. Other considerations, such as second line therapies, utilization metrics, brands for which there exists in that class of drugs commonly used and safe generics, are additional factors. The formulary is set annually with changes quarterly as required.