Beginning January 1, 2010, Horizon Blue Cross Blue Shield of New Jersey will implement a new formulary for fully-insured groups whose prescription benefit includes prior authorization. This change applies to employers with 2-100 employees.

WHAT THIS MEANS TO YOU AS AN EMPLOYER?
The new Advantage Formulary incorporates Utilization Management (UM) programs and prior authorization processes that require members to try a first tier medication. Select brand name drugs will be covered after a first-tier medication has been tried. These UM programs encourage the use of lower-cost generics, when available, as alternatives to brand name drugs within the same therapeutic class.

The types of therapies included under the Advantage Formulary that would trigger prior authorization include, but are not limited to:

• Proton pump inhibitors (Aciphex, Kapidex, Nexium)
• Antihistamines/Combinations (Xyzal, Allegra D)
• Nasal steroids (Veramyst, Nasacort AQ)

If a physician determines that a non-preferred drug is medically necessary due to the
ineffectiveness or documented intolerance to a generic, the physician can request approval for the non-preferred drug to be covered.

To minimize point-of-sale disruption, a new, smart prior authorization process looks back into the member’s prescription claims history, and if it determines that the member has obtained a 30-day supply of a specific generic drug within the last 730 days, then the prior authorization process is bypassed.

WHAT SHOULD I DO NEXT?
Please communicate this important information to your enrolled employees. If you have any additional questions regarding the information within this eCommunication, please call Corporate Synergies at 1.866.CSG.1719 or CLICK HERE to contact us today.

Corporate Synergies is pleased to provide regular updates on issues affecting group benefits insurance. As an insurance broker and consultant, Corporate Synergies monitors federal and state legislative and regulatory activity to ensure that you stay informed.