Pharmacy Utilization Management Programs
The Pharmaceutical Utilization Management (UM) Programs help ensure access to medically necessary, appropriate and cost-effective drug therapy.
Formulary and Alternatives
The formulary provides cost-effective pharmacotherapy based on prospective, concurrent and retrospective review of medication therapies and utilization. The medications included in the formulary are reviewed and approved by the Pharmacy and Therapeutics Committee, which includes practicing physicians and pharmacists from the Horizon NJ Health provider community.
The Formulary List is updated annually and as changes are made or new medications are approved. The Formulary List is updated as of the date that formulary changes are put in place. Changes to the Formulary List are included in the provider newsletter mailed to all providers.
- Covered pharmaceuticals are in the “Formulary List” noted below.
- Copayment: The amount a person must pay for a health care service at the time the service is given.
Copayment: The copayments for prescription drugs (retail pharmacy) are listed in the chart below.
| Benefit Plan | Copayment |
| NJ FAMILYCARE A | $0 |
| NJ FAMILYCARE ABP | $0 |
| NJ FAMILYCARE B | $0 |
| NJ FAMILYCARE C | $1 for generic drugs $5 for brand-name drugs |
| NJ FAMILYCARE D | $5 for generic and brand-name drugs $10 if greater than a 30-day supply |
- Pharmaceuticals that require prior authorization are noted in the Formulary List below.
- Please note that Horizon NJ Health maximum days supply limit is 30 days.
For questions regarding the Horizon NJ Health Maximum Allowable Cost (MAC) program, please contact the Pharmacy Network Manager or Pharmacy Network Coordinator at 1-800-682-9094, x89165 or x89076.