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Horizon BCBS NJMedicare Advantage · Administrative · Prior Authorization · NJMedium impact

Navigating Formulary Utilization Management

Act
immediately
Effective date
Not stated in the notice
Identified
Oct 3, 2026

Summary

This policy provides updated guidance for Horizon Blue Cross Blue Shield of New Jersey members on how to navigate formulary utilization management, including checking medication formulary status, identifying prior authorization (PA) and quantity limit (QL) requirements, and submitting requests for formulary exceptions, tier exceptions, prior authorization, and quantity limit reviews. The policy clarifies the process for Medicare Part D, Braven Health, and Commercial plan members through the Prime Therapeutics portal (myprime.com).

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What to do

immediately · 4 steps
01Billing team and providers must familiarize themselves with the updated myprime.com portal navigation process for all three member types (Medicare Part D, Braven Health, and Commercial plans).
02Update internal workflows and staff training to reflect the new step-by-step instructions for checking formulary status, identifying PA/QL requirements, and submitting exception requests.
03Ensure all staff know the correct contact information for submitting cases: Commercial plans use 1-888-214-1784 or 1-877-897-8808 (fax); Medicare Part D/Braven Health use 1-800-693-6651 or 1-800-693-6703 (fax).
04Verify that clinical staff can access the Prior Authorization Criteria PDFs for both Medicare and commercial plans before prescribing medications.
If missed: Failure to follow these procedures may result in delayed approvals, denials, or claim rejections.

Original notice

Navigating Formulary Utilization Management
horizonblue.com · Always check the source before changing claims.
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