NMHC offers a formulary or preferred drug list for all benefit plans. The NMHC pharmacy benefit is provided and managed by OptumRx®, one of the industry’s largest and most experienced Pharmacy Benefit Managers (PBM).
Pharmacy & Therapeutics Committee
The NMHC formulary and the policies and procedures regarding managing the formulary are reviewed and approved by the NMHC Pharmacy & Therapeutics (P&T) Committee, which is comprised of actively practicing physicians, actively practicing pharmacists and other licensed health care professionals. P&T Committee members exercise their professional judgment in making determinations based on clinical and scientific evidence and analyses. The P&T Committee reviews the formulary and policies annually, and updates occur as information from the Food and Drug Administration (FDA), Centers for Medicare & Medicaid Services (CMS), or when sound clinical evidence becomes available.
In its evaluation, review, guidance and clinical recommendations, the P&T Committee shall:
- Make recommendations on the therapeutic placement and appropriate prescribing guidelines for prescription drug products, and as appropriate, medical device products, intended for use in an ambulatory care setting.
- Provide ongoing review and monitoring of the safety, effectiveness, and quality of care of products contained within the formulary and in NMHC’s clinical programs.
- Initiate and/or review recommended DUR and DUE programs.
- As necessary, review, advise, and approve utilization management guidelines, including prior authorization, step therapies and quantity limits.
- Advise NMHC on suitable educational programs (e.g., for health care provider networks, Plan Participants, and pharmacy providers).
- Make recommendations for the implementation of effective product utilization control procedures.
In addition to making clinical recommendations to the formulary, the P&T Committee shall provide information to medical, health care, and related pharmacy benefit professionals on matters pertaining to the clinical management of prescription drug and medical device usage by:
- Establishing policies and procedures to educate and inform health care professionals about products, product usage, and the P&T Committee’s clinical recommendations;
- Overseeing quality improvement programs that employ product use evaluation;
- Providing recommendations for implementation of generic substitution and therapeutic interchange programs based upon clinical and medical analysis and assessment; and
- Evaluating, analyzing and reviewing protocols for the use of and access to non-formulary products.
Additional responsibilities may be established and delegated to the P&T Committee, as determined by the Chief Medical Officer.
The P&T Committee maintains the formulary for outpatient medications, which may be prescribed by any NMHC provider without Prior Authorization. NMHC providers are required to use formulary medications whenever medically appropriate. Specialty medications must be received from BriovaRx®. Pharmacists will not fill prescriptions for NMHC members for non-formulary drugs unless an approval has been received from OptumRx. Limits and quotas on drugs are set as needed by the P&T committee based on best medical evidence and communicated to providers through regular provider updates such as newsletters or other communications.
NMHC’s formulary is available on our website at http://www.mynmhc.org/Formulary.aspx. If you need assistance with the formulary or in obtaining authorization, call OptumRx at 1-855-577-6550. Formulary exceptions are processed by OptumRx based on medical necessity.
Covered medications include:
- Up to a 30-day supply of drugs requiring a prescription under state or federal law.
- Up to a 90-day supply of drugs when purchasing through the mail order program.
- Generic drug coverage at no cost for hypertension, depression, bipolar disorder, chronic obstructive pulmonary disease, coronary artery disease, hypercholesterolemia, diabetes, congestive heart failure, asthma, and medications for oral chemotherapy.
- Specialty medications with prior approval.
The prescription drug benefits for NMHC members are listed on the member ID card. For member convenience, we also offer a mail order prescription service for ongoing maintenance medications.
Exclusions include but are not limited to:
- Non-prescription drugs
- Compound medications
- Medications excluded by regulation as described by the Centers for Medicare & Medicaid Services (CMS)
- Personal care items
- Cosmetic drugs
- Appetite suppressants, dietary supplements, prescription vitamins (other than prenatal), fluoride products
Participating practitioners may request the addition of a product to the formulary by submitting a request along with any supporting information to the NMHC Medical Management Team. The request will be presented at the subsequent P&T Committee for review and consideration. The P&T Committee decision will be provided to the requesting practitioner within fifteen (15) days following the P&T Committee meeting.
Formulary Exceptions, Prior Authorizations and Appeals
All requests requiring approval for formulary exceptions should utilize the Drug Prior Authorization Request Form and should be faxed to OptumRx at 1-866-511-2202. Any questions can be directed to OptumRx at 1-855-577-6550. In all cases, the review and approval/denial of formulary exceptions will be executed as expeditiously as possible (but generally will not take longer than 48 hours). A provider requesting an exception should provide the following information:
- Patient’s name
- Patient’s date of birth
- Patient’s member ID
- Medication requested
- Name of pharmacy the patient accesses to fill prescriptions
- Medical indication for request
- Alternative medicines tried in the past
- Provider contact information
Prospective review procedures and guidelines for formulary exceptions are developed and updated by and in conjunction with the NMHC P&T Committee and other specialist providers who have agreed to work with NMHC and OptumRx to provide expert guidance. In the event that a request for a coverage determination cannot be approved with the available clinical information, the prescriber, and the member are notified telephonically and in writing of the coverage determination. The written notification to the provider and the member will contain the rationale for the determination and a description of the appeal process. Additionally, the drug use by NMHC members is reviewed to determine if use is appropriate, safe, and meets current medication therapy standards.
The prescribed drug will be considered for coverage under the pharmacy benefit program when the following criteria are met:
- A formulary alternative is not appropriate for this patient (e.g., patient has a contraindication or intolerance to the formulary alternative, etc.); and
- The medication is being prescribed for an FDA approved indication OR the patient has a diagnosis that is considered medically acceptable in the approved compendia* or a peer-reviewed medical journal; and
- The patient does not have any contraindications or significant safety concerns with using the prescribed drug.
A lifetime approval will be granted for patients who meet the above criteria. If the patient does not meet the above criteria, the prescribed use is considered experimental/investigational for conditions not listed in this coverage policy section.
NMHC utilizes the OptumRx Essential Health Benefits formulary. When a new generic comes to market, the formulary is automatically updated. The brand-name equivalent drug will be removed from the formulary. NMHC will notify providers and members of these changes.
A therapeutic interchange will only be made if a provider has received and approved a recommendation for a medication change. OptumRx does not automatically perform therapeutic interchanges.
OptumRx notifies NMHC of changes to all Utilization Management programs, including Step Therapy, on a monthly basis. NMHC will notify members who may be negatively affected by these changes.
NMHC members and providers are encouraged to use online tools available at the OptumRx website. Some actions a member or provider may perform online include:
- Determine copay or coinsurance amount for a medication
- Initiate the exception process
- Order a refill for an existing, unexpired mail order prescription
- Locate in-network pharmacies
- Determine potential drug interactions or side effects
- Look for generic substitutes
*The approved compendia includes:
- American Hospital Formulary Service (AHFS) Compendium
- Thomson Reuters (Health Care) Micromedex/DrugDex (not Drug Points) Compendium
- Elsevier Gold Standard’s Clinical Pharmacology Compendium
- National Comprehensive Cancer Network Drugs and Biologics Compendium