Title: The Real Cost of Mounjaro: How Horizon and Prime Therapeutics Keep Patients in the Dark

By Miles Carter

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Introduction

If you’ve ever paid coinsurance on a high-cost prescription drug and wondered why your share seems so high, you’re not alone. I’m a Horizon BCBSNJ member prescribed Mounjaro, a drug that retails in the U.S. for over $1,000 per month. Despite paying 50% coinsurance, I’ve been blocked from seeing what the actual cost of the drug is to my insurer. The reason? A deeply flawed and opaque rebate system managed by a Pharmacy Benefit Manager (PBM) called Prime Therapeutics.

In this blog post, I break down what happened, how much money might be changing hands behind the scenes, and why this broken system matters to every insured patient in New Jersey and beyond.

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The Setup: Who’s Involved?

• Horizon BCBSNJ: My insurer, who sets my drug coverage benefits.
• Prime Therapeutics: A PBM contracted by Horizon to negotiate drug prices and manage pharmacy benefits.
• Eli Lilly: The manufacturer of Mounjaro.

PBMs like Prime negotiate confidential rebates from drug manufacturers. These rebates are retained by the PBM or shared with the insurer—but they are not shared with the patient, nor are they used to reduce your out-of-pocket cost at the pharmacy counter.

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My Experience: Paying 50% of a Price I’m Not Allowed to See

Under my plan, Mounjaro is a Tier 2 drug with a 50% coinsurance requirement. That means I’m supposed to pay half of the drug’s cost after my deductible. But here’s the catch:

• Horizon calculates my 50% share based on a **non-transparent “approved amount.”
• That approved amount may or may not reflect rebates from Eli Lilly.
• I’m prohibited from knowing the true net price Horizon or Prime paid.

Despite multiple appeals and a formal complaint to the NJ Department of Banking and Insurance (DOBI), I was told that rebate details are confidential under a non-disclosure agreement between Prime and Horizon.

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Real Numbers: Who’s Actually Paying What?

Eli Lilly lists Mounjaro in the U.S. at about $1,000 to $1,100 per month. But in Ireland, the same drug is sold for approximately $250 per month. That price disparity reveals just how inflated the U.S. market is—and just how large the rebates likely are.

Industry analysts suggest PBMs and insurers may be receiving rebates of 60% to 75% on drugs like Mounjaro.

Here’s what that could mean:

Rebate %	Monthly Rebate (Est.)	Annual Rebate (Est.)
50%	$500–$550	$6,000–$6,600
60%	$600–$660	$7,200–$7,920
70%	$700–$770	$8,400–$9,240

Meanwhile, I paid $500–$550 a month, totaling over $6,000 a year out-of-pocket, without a single dollar of that rebate being used to reduce my cost.

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The Bigger Problem: No Transparency, No Oversight

DOBI told me they receive quarterly rebate reports from Horizon, but they don’t show per-drug rebates or how the funds are used. They confirmed they can’t compel Horizon to disclose what price was used to calculate my cost.

This leaves:

• No transparency for consumers,
• No regulatory teeth to challenge inflated cost-sharing,
• No accountability when insurers retain rebates that come from the patient’s usage.

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What Needs to Change

If Horizon can negotiate massive rebates with manufacturers, why can’t they negotiate lower point-of-sale prices for the members they insure?

By choosing to only negotiate rebates—which they keep—and not lower prices for patients, Horizon has abandoned its duty to act in good faith toward its members. Delegating negotiation to a PBM doesn’t absolve Horizon of responsibility. And PBMs like Prime Therapeutics aren’t subject to the same regulatory rules, meaning the entire system sidesteps consumer protection.

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What You Can Do

• File a complaint with the FTC or your state insurance department.
• Contact your legislators to support bills requiring point-of-sale rebate application.
• Share your experience so that these practices can no longer hide behind NDAs.

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Final Thought

This isn’t just about Mounjaro. It’s about a system where consumers bear the cost while others keep the savings. Until rebates are transparent and patients are treated as stakeholders instead of revenue streams, this will continue.

Let’s change that.

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Disclaimer: This blog post is based on my personal experience as a Horizon policyholder and includes publicly available data. Rebate figures are estimated based on industry reports and international pricing comparisons.