Some services require approval (also called prior authorization) from NMHC before you can receive care. The first step in the prior authorization process is to confirm whether a treatment or service is covered by your plan. If the service is not a covered benefit, the prior authorization process will not change this. You can confirm whether NMHC covers a treatment or service by reviewing your Evidence of Coverage Handbook and your Summary of Benefits and Coverage. You also can call Customer Service at 1-855-7MY-NMHC (1-855-769-6642). We can answer prior authorization questions that you or your provider may have.
When a provider in the NMHC network says you should have care that needs prior authorization, the provider must contact NMHC for approval. Our Medical Management team will review the request using nationally recognized guidelines. NMHC and practicing healthcare providers have developed these guidelines. They are consistent with sound clinical principles. If guidelines do not exist for a certain service or treatment, then we use resource tools based on clinical evidence. Examples of services that require prior authorization are:
- Non-emergency inpatient hospital admissions
- Non-emergency surgeries
- Imaging procedures such as MRI, CT scans, and PET scans
- Durable medical equipment (DME) and prosthetics
Please read our statement regarding utilization review decisions here.
Outpatient Prescription Drugs
NMHC uses a Pharmacy Benefits Administrator (PBM) to administer prescription drug benefits. OptumRx is your plan’s PBM. You can contact OptumRx at 1-855-577-6550 or OptumRx.com. NMHC requires you to use a pharmacy in the OptumRx network or OptumRx mail-order program. OptumRx's network includes local retail pharmacies throughout New Mexico and the U.S. and a specialty pharmacy called Briova.
NMHC provides coverage for drugs, supplies, supplements, and administration of a drug (if such services would not otherwise be excluded from coverage). The drugs must be prescribed by a licensed and qualified provider. NMHC offers a $0 copay for most generic drugs for chronic conditions such as asthma, diabetes, and depression, on all plans except for our HDHP and catastrophic plans.
NMHC uses a preferred drug list (formulary). This is a list of prescription drugs that we cover. The formulary includes drugs for a variety of diseases and conditions. If you have questions about our formulary or your outpatient prescription drug benefits, call Customer Service at 1-855-7MY-NMHC (1-855-769-6642). You also can view the formulary on our website at www.mynmhc.org/Formulary.aspx. You’ll find more information about prescription drug limitations and exclusions in the Exclusions section of your Evidence of Coverage Handbook.