Formularies

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 m-edications. 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.

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.

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.

• Prior Authorization Request Form

Fax:
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 website

Prior 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

Information about prescription drug plans and a list of medications available to members on our Centennial Care plan.

Search Online Formulary

• Online Centennial Care Formulary

Download or Print

• Drug Formulary - By Drug Class

Prior Authorization Criteria Document

• Clinical Review Criteria for Coverage for Centennial Care Plans: A list of drugs that have specific edits/requirements

Additional Drug Coverage Information

• Contraceptives Covered with No Co-Pay
• Specialty Pharmaceuticals/Medical Drugs List

Formulary Changes for Current Coverage Year

• Drug Formulary Changes
• Cambios en el Formulario de medicamentos

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

Online Commercial Large Group Plans (Non-Metal Plans) Formulary

Download or Print

• Commercial Large Group Plans (Non-Metal Plans) Formulary – by Therapeutic Class

Prior Authorization Criteria Document

• Clinical Review Criteria for Coverage: A list of drugs that have specific edits/requirements

Additional Drug Coverage Information

• Contraceptives Covered with No Co-Pay
• Specialty Pharmaceuticals/Medical Drugs List

Formulary Changes for Current Coverage Year

• Commercial Large Group Plans (Non-Metal Plans) – Formulary Changes

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

Online Individual and Family Metal Plans/Employer Group Metal Plans Formulary

Download or Print

• Individual and Family Metal Plans/Employer Group Metal Plans Formulary

Prior Authorization Criteria Document

• Clinical Review Criteria for Coverage: A list of drugs that have specific edits/requirements

Additional Drug Coverage Information

• Contraceptives Covered with No Co-Pay
• Specialty Pharmaceuticals/Medical Drugs List

Formulary Changes for Current Coverage Year

• Individual and Family Metal Plan/Employer Group Metal Plans - Formulary Changes

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

• 2023 Medicare Formulary (List of Covered Drugs) - Updated 3/1/2023
• 2023 Medicare Drug Formulary Changes - Updated 3/1/2023
• 2023 Presbyterian Dual Plus (HMO SNP) Formulary (List of Covered Drugs) - Updated 3/1/2023
• 2023 Medicare Step Therapy Criteria - Updated 3/1/2023
• 2023 Medicare Drug Prior Authorization Criteria - Updated 3/1/2023
• Medicare Part B Step Therapy