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Navigating your Patients Pharmacy needs
Act
immediately
Effective date
Not stated in the notice
Identified
Oct 3, 2026
Summary
This is a new guidance document from Horizon Blue Cross Blue Shield of New Jersey explaining how to navigate pharmacy benefits, check medication formulary status, identify prior authorization and quantity limit requirements, and submit coverage determination requests through Prime Therapeutics. The policy provides step-by-step instructions for Commercial, Medicare Part D, Braven Health, and Horizon NJ TotalCare (HMO D-SNP) members.
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What to do
immediately · 7 steps
01Billing and clinical staff must familiarize themselves with the new pharmacy resources and processes outlined in this policy.
02Providers should bookmark myprime.com and HorizonBlue.com/formulary for quick access to formulary lookups and prior authorization criteria.
03Billing team must update internal workflows to require checking formulary status and PA requirements before claim submission for all Horizon BCBS NJ patients (Commercial, Medicare Part D, Braven Health, and HMO D-SNP plans).
04Train staff on the different navigation paths for each plan type (Medicare Part D vs. Commercial vs. Braven Health) to correctly identify non-formulary drugs, quantity limits, and PA requirements.
05Establish a process to submit coverage determination requests (Formulary Exception, Tier Exception, Prior Authorization, Quantity Limit reviews) via the online portal, fax, or phone to the appropriate Prime Therapeutics department based on plan type.
06For Commercial plans, update staff on the electronic prior authorization submission option.
07Post contact information for Commercial (1-888-214-1784 / 1-877-897-8808) and Medicare/Braven Health (1-800-693-6651 / 1-800-693-6703) departments in billing area for easy reference.
If missed: Failure to verify prior authorization requirements before claim submission will result in claim denials.
Original notice
Navigating your Patients Pharmacy needs
horizonblue.com · Always check the source before changing claims.
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