Pharmacy Resources
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 your 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 my Drug is not covered?
You can request an exception.
You or your doctor can ask us to make an exception (prior authorization) to our coverage rules. We will work with your prescriber to get additional information to support your request. There are several types of exceptions that you can ask us to make.
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 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
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
Additional Drug Coverage Information
Formulary Changes for Current Coverage Year
You may obtain more information by calling the Pharmacy Services Team Monday through Friday, from 8 a.m. to 5 p.m., at
or . You can also send pharmacy inquiries to info@phs.org.Large Group Plans
Information about prescription drug plans and a list of medications available to members in our large employer group (51+ employees) plans who have prescription drug coverage provided by Presbyterian Health Plan.
Search Online Formulary
Download or Print
Additional Drug Coverage Information
Formulary Changes for Current Coverage Year
You may obtain more information by calling the Pharmacy Services Team Monday through Friday, from 8 a.m. to 5 p.m., at
or for PIC members and or for HMO members. You can also send pharmacy inquiries to info@phs.org.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
Additional Drug Coverage Information
Formulary Changes for Current Coverage Year
You may obtain more information by calling the Pharmacy Services Team Monday through Friday, from 8 a.m. to 5 p.m., at
or for PIC members and or for HMO members. You can also send pharmacy inquiries to info@phs.org.Medicare Advantage Plans
List of drugs approved by the Centers for Medicare and Medicaid Services (CMS) — that are covered by Presbyterian’s Medicare Advantage prescription drug plans.
ADDITIONAL PHARMACY FORMS & RESOURCES
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.
Forms & Documents
Important forms and documents related to your Presbyterian health insurance plan can be found in Forms and Documents View Forms and Documents
Pharmacy Locations
Search a directory of pharmacies available on Presbyterian health plans. Note that some drugs are required to be obtained through a specialty pharmacy provider Search Pharmacy Locations
myPRES Member Portal
myPRES allows patients, members, and providers to access information and tools designed specifically for them. Login to myPRES
Continuous Glucose Monitors Available for Medicare Advantage Members through Pharmacy Point-of-Sale
FreeStyle Libre 14 Day System
FreeStyle Libre 2 System
Dexcom G6 System
Dexcom G7 System
Things to note:
Members need to satisfy Centers for Medicare and Medicaid Services (CMS) criteria before coverage will be provided by your plan for CGM supplies through the pharmacy at the point-of-sale or a national DME vendor
The member’s Part B copayment or coinsurance under their plan is the same whether the CGM is obtained through a DME or through the pharmacy at the point-of-sale
For coverage guidance, please refer to CMS Local Coverage Determination ID L33822 - Glucose Monitors
If you have questions about CGM coverage through the pharmacy, call
or ((TTY ) 8 a.m. to 8 p.m., Monday – Friday)IMPORTANT PHARMACY COVERAGE INFORMATION
Please be sure a prescription drug benefit is part of your specific coverage before consulting this list. If you do not know which list is correct, please contact our local Pharmacy Services team using the Presbyterian Customer Service Center number listed on the back or your Presbyterian member ID card or email them at askpharmacy@phs.org.
Coverage for some drugs may be limited to specific dosage forms and/or strengths. Your benefit design determines what is covered for you and what your copayment will be. Please refer to your benefit materials for your specific coverage information.
This list is not all-inclusive, nor does it imply a guarantee of coverage. In addition, coverage for some drugs listed may be limited to specific dosage forms and/or strengths. Substitution of a generic product for a brand-name drug is mandatory when a generic equivalent is available. If a member requests the brand-name drug in this situation, a pharmacy exception may be required, and the member must pay the difference in cost between the generic and branded versions. Non-formulary medications are not considered for coverage unless trial and failure of Formulary alternatives are documented.