New Mexico Health Connections | my connection | Spring 2018

{ T H E O P T U M R X M E M B E R P O R T A L C A N H E L P Y O U S A V E M O N E Y } RX 2 { MY CONNECTION } { M E M B E R N E W S } Important changes to your pharmacy benefit for 2018 T he new year has brought some changes to your New Mexico Health Connections (NMHC) pharmacy benefits. The table below breaks them down for you. Category What you need to know Copayment (copay) tiers There are six copay tiers: •   Two generic tiers. •   One preferred-brand tier. High-potency pain medication program Together with our pharmacy benefit manager, OptumRx ® , we started a program on Jan. 1 to limit the use of opioids and other powerful prescription pain medications. •   The Opioid Risk Management program limits new prescriptions for members who are new to opioid therapy to only a seven-day supply, with an allowance for up to two seven-day supplies within a 60-day period. •   The program also places a maximum dose of opioids that members may receive, and requires that a member use 90 percent of a prescription before getting a refill. General changes to the formulary (list of covered prescription drugs) Our formulary changes from time to time. Some medications are removed and others are added. If a medication that you take is removed from the formulary, you will receive a letter from OptumRx telling you about the change. Don’t forget! • When you go to the pharmacy, always take your NMHC member ID card with you. This will help the pharmacy staff fill your prescription efficiently. • If you have questions about your pharmacy benefit, please call NMHC Customer Service at 855-769-6642 . • Find our formulary, a list of in-network pharmacies, information about OptumRx and its mobile app, claim forms, and more at mynmhc.org/formulary.aspx . Looking for a simple way to save time, save money and remember to take your prescriptions? The OptumRx member portal and mobile app can help. Register at optumrx.com and open an account to: •   Look up the price of drugs covered by your NMHC plan. •   Find lower-cost options. •   Refill and renew mail-service prescriptions. •   Sign up for text reminders to take and refill your medicine. What’s your health insurance IQ? KNOW THE L INGO Sometimes, health insurance policies feel like they’re written in a foreign language. You read them and wonder, “What in the world does that mean?” Understanding basic medical insurance terms is important—especially if you’re shopping for a new policy. That knowledge can help you pick the plan that best fits your needs and may save you money. Healthcare.gov provides plain-language definitions of many health insurance terms. You’ll find a list of terms at healthcare.gov/glossary . You can also read definitions of some basic terms below. Premium. The monthly amount you pay for insurance. Coverage. The health services your plan will pay for. Deductible. The amount you’re required to pay for medical care each year before your insurance begins to pay. If you have a deductible of $1,000, you’ll pay $1,000 out of pocket for covered health services before your insurance pays anything. The deductible may not apply to all services. Copay. This is short for copayment . It’s a set dollar amount ($15, for example) you pay each time you see a provider, get a prescription or use another covered health service. Your copay can vary, depending on your plan and the type of service you get. Your insurance company pays the rest of the bill, up to the amount allowed by your plan. Allowed amount. The most your plan will pay for certain healthcare services. If your healthcare provider charges more than your insurance will pay, you may have to pay the difference. Co-insurance. The percentage of the cost of a service that you must pay after you’ve met your deductible. A common co-insurance ratio is 80-to-20. In other words, insurance pays 80 percent of the allowed amount for the service, and you pay 20 percent. Formulary. A list of prescription drugs that your health plan or prescription plan will cover. It’s also called a drug list. In-network/out-of-network. Providers— hospitals, doctors, specialists and therapists, for example—who accept your health insurance are called in-network providers. Ones that don’t are called out- of-network providers. It typically costs you more to see out-of-network providers, so check carefully to see if the healthcare providers you use or are considering using are in-network or out-of-network. Sources: AARP; Centers for Medicare & Medicaid Services •   One non-preferred-brand tier. •   One preferred specialty drug tier. •   One non-preferred specialty drug tier. •   View your order status and claims history. •   View your prescription drug benefits. The OptumRx mobile app lets you take the member portal with you while traveling, to medical appointments and everywhere else. The app is available in the Apple App Store and Google Play. Visit mynmhc.org/formulary.aspx to watch a video about the mobile app that shows how convenient it is to use. Note: The video mentions mail-order service. Your pharmacy benefit may not include this service.