Horizon Brief Notes on Indefinite Authorization Reviews for Horizon Pharmacy Members

See below Horizon Brief Notes on Indefinite Authorization Reviews for Horizon Pharmacy Members

Applies to: Commercial fully insured and self-insured groups
Indefinite Authorization Reviews for Horizon Pharmacy Members

To help your customers’ covered employees achieve their best health, lower costs and ensure appropriate utilization and review of medications, we will be ending all indefinite authorizations on December 31, 2023. After review of these authorizations, we have determined that some medications may still need an authorization (subject to formulary exception or utilization management review) to continue being filled, and some may not require any authorization.

Why We Are Ending Indefinite Authorizations
Our records have identified prescription authorizations for members where there is no end date noted in our pharmacy claims system (indefinite authorizations). This allows for members to continue receiving the drug(s) without any review.

Generally, the maximum duration for drug authorizations is 12 months to ensure annual review for safe and appropriate drug utilization. There are several different reasons why such indefinite authorizations may have been in a member’s profile. Because there is such variability with the history behind these authorizations, not all authorizations underwent a full clinical review for safe and appropriate utilization.

How This Impacts Members and Their Doctors
Members and their doctors received letters in early October about this change and what to do if the affected medication(s) need authorizations going forward. 

If members need the medicine(s), they can fill the prescription(s) until the authorization(s) is no longer active (until December 31, 2023).

After December 31, 2023, the medicine may need a new prior authorization or a formulary exception for the medicine(s) to be covered. 

  • To view their current formulary, members should visit com/formulary and select their formulary to see if their medicine requires any authorization. If it is not listed on their formulary, it will require a formulary exception review.
  • If a review is required, their doctor must give us medical information to show that the use of the medicine(s) meets specific criteria. We will then review the request based on our Formulary Exception and/or Prior Authorization/Medical Necessity Determination requirements 

If they do not need the medicine(s) OR the medicine does not need any authorization to continue filling, there is nothing the member or doctor needs to do.

If a member has questions about their Horizon Pharmacy plan, they can call Pharmacy Member Services at 1-800-370-5088, 24/7.