• If your ID number changes for any reason, please be aware that any existing prior authorizations/approvals (PAs) you have may not transfer to your new ID number.
• NMHC will try to have your PA transferred to your new member ID number when possible, but first, we must be notified. If your ID number has changed and you have an existing PA, please call Customer Service at 1-866-668-9002.
• 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 Provider Forms and Other Resources page (see "Prior Authorization List").
• 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. 

How Does the Prior Authorization/Exception Process Work?

1. You or your doctor may begin the PA/exception process by submitting a Drug Prior Authorization Request Form, which is found on the Member Forms and Other Resources page, to OptumRx.
2. The completed form can be faxed to OptumRx at 1-866-511-2202 for review. Doctors also can call OptumRx directly at 1-855-577-6550 to request a PA/exception.
3. PA/exception requests are processed according to the urgency of the situation. Medically urgent requests are usually processed within 24 hours of receipt. Standard requests are usually processed within 72 hours of receipt. In some situations, these time frames may be extended to allow doctors enough time to supply needed clinical information.
4. Once a decision about your PA/exception request is made, you will be notified. If the request is approved, you will receive a letter, which is mailed within one day of the date of the decision. If your request is denied, you will be notified by phone within one day and will also receive a letter. 

What If My Prior Authorization/Exception Request Isn’t Approved?

Opioid Abuse and Misuse: Get the Facts

Misuse or abuse of high-potency prescription pain medications (opioids) is a serious public health issue. The Centers for Disease Control and Prevention (CDC) reports that, since 1999, prescription-opioid-related overdose deaths have quadrupled. Data from the U.S. Department of Health and Human Services shows that 44 Americans die from prescription opioid overdose every day.

Learn essential information about this class of prescription drugs, prescribing guidelines, safer alternative medications, storage and disposal tips, and information preventing misuse and overdose from OptumRx.

Do you need help locating an opioid treatment (buprenorphine) prescriber? Click here to locate a provider. Note: This provider list is not comprehensive. Please be sure to call Customer Service at 1-866-668-9002 to confirm that the provider you have selected is in the NMHC network.

OptumRx Specialty Services

OptumRx's Specialty Pharmacy is included as part of the pharmacy benefit program for members who are receiving specialty medications. OptumRx Specialty Services provides a hands-on service to help you get the special treatment you need for complex conditions including cancer, arthritis and others. To enroll or learn more about OptumRx Specialty Services, please call 1-855-427-4682 or visit www.BriovaRx.com.

Preferred Copay Card Acceptance Program

NMHC has adopted OptumRx's Preferred Copay Card Acceptance program. However, OptumRx Specialty Services will not accept copay cards (coupons) for all specialty drugs in the formulary. View a list of the specialty drugs for which OptumRx Specialty Services will not accept copay cards. The list includes preferred lower-cost options for these drugs.

Manufacturer Copay Cards for Specialty Drugs and Accumulations (Accrued Copay and Coinsurance Amounts)

Effective January 1, 2019, only the amount you actually pay for your prescriptions will be applied toward your deductible and out-of-pocket maximum when using a manufacturer copay card filled at OptumRx Specialty Services. Prior to January 1, the full value of your manufacturer copay card was applied to your deductible and out-of-pocket maximum.

Manufacturer copay card programs are used to help lower patient copay and coinsurance amounts. Not all specialty medication manufacturers offer copay assistance, but many do. To find out if a specialty medication manufacturer does offer a copay card program, you can do an Internet search for the name of the specialty drug along with the search terms "copay assistance" or "copay card." Manufacturers usually place limits on their copay card programs.

This change does not require you to take any additional action. You may continue to fill your prescriptions as usual. If you have questions, please call NMHC Customer Service at 1-866-668-9002.

Oral Chemotherapy Split-Fill Program

If you are taking specialty chemotherapy drugs by mouth, please read this important notice to learn if your medication is on our "split-fill" list.

Mail-Order Pharmacy

• Individual plan members can use OptumRx Home Delivery, but they can receive only a 30-day supply of medication via mail-order.
• Ninety-day medication supplies are not a covered benefit for individual plan members.
• OptumRxHome Delivery does not provide Specialty Pharmacy medications by mail.