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2023 Updates to Prescription Drug formularies

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Horizon is constantly looking for ways to navigate managing costs especially in these trying times with inflation on the rise. For this reason, Horizon updated its list of formulary and non-formulary drug list that will help drive utilization toward safe, effective and less-costly medicines.  

This new update applies to Individual, Small Group and Midsize Fully Insured (Excluding Public Sector) and Level Funded Markets.

What is a formulary?
There are a few types of formularies. An open formulary has no limitation to access a medication. Open formularies are generally large. A closed formulary is a limited list of medications. A closed formulary may limit drugs to specific physicians, patient care areas, or disease states via formulary restrictions.  

Formulary’s are determined by a pharmacy and therapeutics committee. P&T committees are primary care and specialty physicians, pharmacists and other professionals in the health care field. Formulary changes typically occur twice a year.
Formulary changes happen if drugs are: Recalled from the market; Replaced by a new generic drug; or, Clinical restrictions are added, including, but not limited to, prior authorization, quantity limits or step therapy.
  Its important to have the Formulary Management Process because such efficient and effective use of health care resources minimizes overall medical costs, improves patient access to more affordable care and provides an improved quality of life.
Some Medicines Will Be Non-Formulary
Effective January 1, 2023, some medicines will be moving to a non-formulary status. Covered employees and their covered dependents who are impacted by this change — as well as their doctors — have been notified via mail. An alternative drug is available for every medicine that moves to non-formulary status.

Medicines that are now going to be a non-formulary status will remain eligible for coverage under the members’ pharmacy benefits at the same level as formulary medicines, if medically necessary. Members who are affected and their doctors have been notified as to which formulary alternatives are available.

Next Steps for Impacted Members
If a member’s doctor believes it is medically necessary to continue taking a non-formulary medicine, the physician can submit a Formulary Exception form to Prime Therapeutics, Horizon’s pharmacy benefit manager. The Formulary Exception form will then be reviewed and a decision made.

For further questions, or if you need information about formulary alternatives or need help with requesting a formulary exception, you can call Horizon Pharmacy Member Services at 1-800-370-5088 24/7.

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