- 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 1-855-769-6642.
- 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 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 (PA)/Exception Process Work?
If your provider determines that you need access to a drug that is not on the NMHC formulary, a Prior Authorization (PA) may be submitted for review. You or your provider may begin the PA process by submitting a Drug Prior Authorization Request Form to OptumRx. You can find this form on the Member Forms and Other Resources page.
Once completed, the form may be faxed to OptumRx at 1-866-511-2202 for review. Providers also can call OptumRx directly at 1-855-577-6550 to request a PA.
Prior Authorization/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. There may be situations in which these decision time frames are extended in order to allow providers sufficient time to supply necessary clinical information.
Once a decision about your PA request is made, you will be notified. For denials, you will be notified by phone within one day and a hard-copy letter will follow. If the request is approved, you will receive a letter, which is mailed within one day of the date of the decision.
What If My Prior Authorization/Exception Request Isn’t Approved?
Remember: A PA is not always approved. You and your provider will receive written notice about our decision. Each notice will include your options and appeal rights. To learn more, please review the Prior Approval section in your NMHC member handbook (Evidence of Coverage).
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.
BriovaRx® Specialty Pharmacy
BriovaRx, OptumRx's Specialty Pharmacy, is included as part of the pharmacy benefit program for members who are receiving specialty medications. BriovaRx 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 BriovaRx, please call 1-855-427-4682 (1-855-4BRIOVA) or visit www.BriovaRx.com.
Preferred Copay Card Acceptance Program
NMHC has adopted OptumRx's Preferred Copay Card Acceptance program. However, BriovaRx will not accept copay cards (coupons) for all specialty drugs in the formulary. View a list of the specialty drugs for which BriovaRx 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 BriovaRx Specialty pharmacy. 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 1-855-769-6642.
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
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Individual plan members can use OptumRx Home Delivery, but they can receive only a 30-day supply of medication via mail-order.
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Ninety-day medication supplies are not a covered benefit for individual plan members.
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OptumRxHome Delivery does not provide Specialty Pharmacy medications by mail.