Updates to the OptumRx Formulary (Drug List)
Machine-Readable JSON Drug Formulary file – Machine-readable formatting provides an electronic version of a document so it can be read or deciphered by a computer. All machine-readable documents are formatted with similar coding and provide a universal method for a computer to "read" documents. NMHC is required to post some of our documents in machine-readable format. Because of how they appear, machine-readable formats are typically not easy for humans to read.
||April 1, 2017
||Added as a non-preferred brand|
|Utilization management changes|
||March 1, 2017
||The Darzalex PA program has been updated to include the new indication for use in combination with Revlimid (lenalidomide) and dexamethasone or Velcade (bortezomib) and dexamethasone, for the treatment of patients with multiple myeloma who have received at least one prior therapy.|
||April 1, 2017
||The quantity limits for Zofran and ondansetron 4 mg and 8 mg tablets will be retired.|
Important Note about Switching Plans and Prior Authorization
If you have switched from one NMHC plan to another – for example, from an individual to a group plan, or from one NMHC group plan to another – please be aware that any existing prior authorizations/approvals (PAs) you have may not transfer over to your new plan.
NMHC will try to have your prior authorization transferred to your new member ID when possible, but first we must be notified. If you have switched plans and have an existing PA, please call Customer Service at 1-855-7MY-NMHC (1-855-769-6642).
- To learn more about prior authorizations, please refer to the Prior Authorization section of our Seeking Healthcare Services page.
- Find a list of services that need prior authorization on our Medical Management page.
- Our formulary (drug list), found on this page, also notes a “PA” next to the medication name for drugs that require a PA. Your doctor or prescriber must start the PA process for you. Your provider can find the PA Request Form on our Provider Forms and Other Resources page.
Important Notices for Asthma and Diabetes PatientsIf you have asthma or diabetes, we urge you to read this information about the asthma and diabetes medications and supplies that are on our formulary (list of covered drugs). Using medications on this list – which includes generic drugs, preferred drugs, and $0 copay drugs – can help lower your out-of-pocket expenses. Talk to your provider about these medications.
Prescription drug information for members with asthma and/or diabetes
OptumRx's 72-Hour Emergency Medication Fill Process for NMHC Members
If you need a medication refill and the pharmacy’s system shows that you are ineligible, OptumRx can process a 72-hour emergency fill of your medications. You must call OptumRx at 1-855-577-6550 to begin the process. The pharmacists cannot request this exception. All drugs except narcotics will be eligible for the 72-hour emergency fill. This new process will be helpful when processing errors, system errors, or other delays due to downed communication channels occur.
Upon receiving a call from you, OptumRx will load you into the pharmacy’s system with a pre-defined ID number that will allow the pharmacy to fill your prescription. OptumRx will notify you once this process is complete so that you can return to the pharmacy to pick up the medication. Afterwards, OptumRx and NMHC will investigate each member call to ensure that those members are indeed eligible.