Updates to the Formulary
No updates.
Formulary (Drug List) Alternatives
We want you help you get the most out of your prescription drug benefit and save money wherever possible. The list below may help you find alternatives to drugs that are not on the formulary, that are non-preferred drugs, or that require prior authorization or step therapy.
The OptumRx Pharmacy Network
Note: This list is sorted by city. To search for a pharmacy by name in this list, hit Ctrl + F on your keyboard to activate the "Find" function, if you are using a PC. If you are using a Mac, hit Command + F.
To find a pharmacy in OptumRx's national network, please log in to your account at OptumRx.com and enter a zip code under the Pharmacy Locator heading.
Important Information about ID Number Changes and Prior Authorization
- 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 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.
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).
Important Notices for Asthma and Diabetes Patients
If 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.
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.
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 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.
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SHOP (on-exchange) group plan members can use OptumRx Home Delivery and can receive up to a 90-day supply of medication via mail-order.
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Beginning July 1, 2018: OptumRx Home Delivery will no longer dispense more than a 30-day supply of opioid medications at one time for any patient (whether on an individual or a SHOP plan). We are making this change to support safe, appropriate use of opioids and to limit excess supply in the market.
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If you are a SHOP group member requesting a 90-day supply, note that your cost-share (copayments) will be the same for mail-order as at a retail pharmacy.
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Not all NMHC members have a mail-order pharmacy benefit. Please call NMHC Customer Service at 1-855-769-6642 to determine your mail-order pharmacy coverage.
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OptumRx Home Delivery does not provide Specialty Pharmacy medications by mail.
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If you're not sure which type of NMHC plan you have, look at your insurance ID card. Individual plan members have an ID number beginning with 000 or P7. SHOP group members have a five-digit ID number.
Pharmacy Forms and Notices for NMHC Members
Pharmacy Notices for NMHC Providers
Criteria Sets
Providers contracted with NMHC may request copies of our criteria sets from OptumRx by calling 1-855-577-6550.
Drug Safety Reports
Download a PDF of our drug safety report for the second quarter of 2018.
Drugs Covered under Medical vs. Pharmacy Benefit
Some medications are covered under the NMHC medical benefit, while others are covered under the OptumRx pharmacy benefit. While not all-inclusive, this comparative list will help educate you about the differences between the two classifications.
Opioid Risk Management Program
NMHC members are subject to the OptumRx Controlled Drug Management program. This program limits the dose/quantity of opioids that members can receive. We have collected several resources for NMHC providers to use when prescribing opioids or requesting prior authorization for their patients who are NMHC members. You will find these resources on the Provider Forms & Other Resources page under the Opioid Risk Management Program heading.