Prescription drugs account for 20 cents of every premium dollar you pay as a Horizon member. That’s in addition to what you will pay at the pharmacy checkout in co-pays or coinsurance. 

And prescription costs continue to rise. According to Reuters, drugmakers launched new medications at “record-high” prices in 2022. Many of these drugs were specialty drugs, breakthrough drugs for complex conditions for which few treatment options are available. One example: In November of 2022, a new gene therapy for hemophilia was approved by the Federal Drug Administration (FDA) with a one-time treatment price tag of $3.5 million. Called Hemgenix, it is cited as the most expensive drug ever.

A prescription formulary lowers costs for members

To keep your costs in check, Horizon takes a number of steps, including building a strong network of pharmacies and giving doctors tools that show them what a patient will pay for a prescription and suggestions for lower-cost alternatives when appropriate.

The most important tool health plans like Horizon use is a formulary, or the list of drugs each plan covers and the member costs.  

A group of doctors and pharmacists are part of a pharmacy and therapeutics (P&T) committee that approves the formulary based on safety and effectiveness according to the latest independent evidence, and cost. When more than one drug exists to treat a particular condition, health plans negotiate with the suppliers to get the best price for members.  

It’s not uncommon for different pharmaceutical companies to introduce a new medication that is almost identical to an existing medication with the same active ingredients. When this happens, Horizon can negotiate with suppliers to get a lower price by only including one of the drugs in the formulary.  

Our formulary is updated at least quarterly, as well as when changes are made or new medicines are approved. These changes are included in the member newsletter that we mail to all members.

We offer a “tiered” system that helps you choose from different options and prices

Our members take thousands of different prescription drugs each year, with more drugs being introduced all the time. Horizon’s goal is to make sure you can get the prescriptions you need at the most affordable cost.  A tiered formulary and pricing system helps Horizon provide access to a wide array of medications while keeping costs more affordable across the board for everyone.

• Tier 1: Lowest out-of pocket costs: These medications offer the most value for the money. Most are generic medications that are approved by the FDA and contain the same active ingredient as the brand-name counterparts but are far less costly. Nearly 90% of prescriptions are generics.
• Tier 2:  Higher out-of-pocket costs: Tier 2 drugs meet the safety and effectiveness of Tier 1 drugs, but are more expensive, hence the higher out-of-pocket cost. 
• Tier 3 : Highest out-of-pocket costs: Tier 3 drugs have not shown to be more effective, safe and/or unique compared to their counterparts. Thus, they come with a far higher price tag.

What if my doctor wants to prescribe a drug that isn’t included in my plan’s formulary?

Horizon’s goal is to ensure that you get the prescriptions you need to achieve your best health.  If your doctor believes that you must have a drug that is not on our formulary and you want Horizon to cover that drug, your doctor will need to work with us to get coverage approval (they may call it prior authorization). This involves your doctor describing why a certain prescription, and not the similar or identical drug in the formulary, is necessary to treat your condition.   

Are there other ways I can lower my medication costs? 

Yes. In fact, there are a number of ways you can choose the right medication and help reduce your out-of-pocket costs. 

• With the Real Time Benefit tool, your doctors can check your current medications, your insurance information and out-of-pocket costs, along with a list of up to three lower-cost alternatives and the pharmacies where they are available.
• MyPrime is an online information hub that helps you access your prescription information, understand your choices, and find the lowest-cost option.
• Through the Rx Savings Solutions online tool, you can receive alerts on how to find and fill lower-cost prescription medications. People who enrolled in Rx Savings Solutions have saved an average of $439 out-of-pocket annually on their prescriptions.
• PillPack by Amazon Pharmacy offers Horizon members two options for lower-cost prescription medications: a 30-day supply of multiple medications, organized and pre-sorted so members don’t miss a dose, or a 90-day supply in a bottle – all delivered right to your home.

Is Horizon doing anything else to help lower the cost of prescription drugs?

Generic medications make up most of the medications our members take. However, the prices of some generics, like insulin, have risen substantially. The Blue Cross Blue Shield Association (BCBSA) and 20 Blue Cross and Blue Shield (BCBS) companies – including Horizon– are partnering with non-profit drug maker Civica to help reduce the costs of certain generics for consumers.

Prime Therapeutics LLC is an independent company that supports Horizon Blue Cross Blue Shield of New Jersey in the administration of pharmacy benefit management and specialty pharmacy services.

RX Savings Solutions is contracted by Horizon Blue Cross Blue Shield of New Jersey to provide lower-cost prescription medications to eligible members.

Amazon Pharmacy is contracted by Horizon Blue Cross Blue Shield of New Jersey to provide pharmacy home delivery services to eligible members.