Formularies for Providers
The Presbyterian pharmacy benefit is an essential element in providing patients and members the medication they need while appropriately managing costs. Formularies include both brand name and generic medications that are commonly prescribed. Refer to the formularies to see if the drug prescribed is covered by the plan.
UNDERSTANDING PHARMACY BENEFITS
What is a Formulary?
A drug Formulary, or preferred drug list, is a continually updated list of medications and related products supported by current evidence-based medicine, judgment of physicians, pharmacists and other experts in the diagnosis and treatment of disease and preservation of health.
The primary purpose of the Formulary is to encourage the use of safe, effective and most affordable medications. Presbyterian Health Plan administers a closed Formulary, which means that non-formulary drugs are not routinely reimbursed by the plan. Medical exceptions policies provide access to non-formulary medication when Medical necessity is established.
The medications listed on the Formulary are subject to change per the management activities of Presbyterian Health Plan Pharmacy and Therapeutics Committee pursuant to N.M.S.A. 1978, §59A-23-7.13.
Can the Formulary change during the year?
The Formulary can change throughout the year. Some reasons why it can change include:
New drugs are approved
Existing drugs are removed from the market
Prescription drugs are removed from the market.
Prescription drugs may become available over the counter (without a prescription).
Brand-name drugs lose patent protection and generic versions become available.
Changes based on new clinical guidelines.
If we remove drugs from our Formulary, add quantity limits, prior authorization, and/or step therapy restrictions on a drug; or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective.
What if the prescribed Drug is not covered?
You can request an exception.
Providers, members, and member representatives can ask us to make an exception (prior authorization) to our coverage rules. We will work with the prescriber to get additional information to support the request. There are several types of exceptions that can be requested.
You can ask us to cover your drug even if it is not on our formulary.
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
Refer to your member handbook for more information about exceptions and the prior authorization process.
How to request an exception.
To request an exception, you or your appointed representative should call the Presbyterian Customer Service Center at the number listed on the back your ID Card.
You, your doctor, or pharmacist can submit a request by fax or mail.
- OR -
Complete and submit Prior Authorization onlineFax: 505-923-5540
Mail: PHP Pharmacy Department P.O. Box 27489 Albuquerque, NM 87125-7489
If you are a Medicare Advantage member, visit your plan specific websitePrior Authorization Request Processing Times
Standard Pharmacy PA Requests: When all necessary information is provided with the Drug PA request, standard requests are processed as expeditiously as the member’s health requires, within 72 hours after the request is received.
Expedited Pharmacy PA Requests: When a member or their provider believes that waiting for a decision under the standard time frame could place the member’s life, health or ability to regain maximum function in jeopardy, a PA can be expedited. These requests are processed within 24 hours after the request is received.
If additional information is required in order to decide on a PA, Presbyterian Pharmacy Services will contact your prescriber by phone and, if necessary, by fax.
Once a decision has been made, you will receive a notification with either an approval or adverse determination.
Learn more about Presbyterian's Nondiscrimination Notice and Interpreter Services
FIND YOUR DRUG COVERAGE INFORMATION
Medicaid Centennial Care Plans
Information about prescription drug plans and a list of medications available to members on our Centennial Care plan.
Search Online Formulary
Download or Print
Prior Authorization Criteria Document
Additional Drug Coverage Information
Formulary Changes for Current Coverage Year
Large Group Plans
Information about prescription drug plans and a list of medications available to members in our large employer group plans who have prescription drug coverage provided by Presbyterian Health Plan.
Search Online Formulary
Download or Print
Prior Authorization Criteria Document
Additional Drug Coverage Information
Formulary Changes for Current Coverage Year
Health Insurance Exchange Metal Level Plans
Information about prescription drug plans and a list of medications available to members on our individual and family plans or on a small employer group (1-50 employees) plans. (Applies to both on and off exchange plans.)
Search Online Formulary
Download or Print
Prior Authorization Criteria Document
Additional Drug Coverage Information
Formulary Changes for Current Coverage Year
Medicare Advantage Formularies and Formulary Updates
List of drugs approved by the Centers for Medicare and Medicaid Services (CMS) — that are covered by Presbyterian’s Medicare Advantage prescription drug plans.
Search Online Formulary
Online Presbyterian Medicare Advantage Formularies
Download or Print
Specialty Pharmaceuticals/Medical Drugs List
A list of medications identified as Specialty Pharmaceuticals (self-administered) and Medical Drugs (provider administered). Some of these medications may involve unique distribution and may be provided by Presbyterian’s Specialty Care Pharmacy. Prior authorization or medical exception may be required on some medications.
ADDITIONAL PROVIDER RESOURCES
SureScripts Tool
You can use our SureScripts tool to see if pharmacy prior authorization is required.
Additional Provider Pharmacy Forms
Recalls, Market Withdrawals, & Safety Alerts
U.S. Food and Drug Administration (FDA) Safety Alerts
U.S. Food and Drug Administration (FDA) Drug Recalls
Mail Order Prescriptions
Presbyterian offers mail-order prescriptions in partnership with Optum Home Delivery. Order up to a 90-day supply of maintenance drugs (as prescribed by your physician) and get free delivery to your home with Optum Home Delivery.
Prescription Drug Reimbursement
Form used to request direct member reimbursements.
myPRES Member Portal
myPRES allows patients, members, and providers to access information and tools designed specifically for them. Login to myPRES
You may obtain more information by calling the Pharmacy Services Team Monday through Friday, at
or . You can also send pharmacy inquires to info@phs.org.
