Pharmacy/Formulary

• Small group formulary changes for 2023
• Large group formulary changes for 2023

• $0 Generic Drugs
• $0 Oral Oncology (Cancer) Drugs
• $0 Preventive Drugs, HDHP Plans Only
• No-Cost Preventive Drugs Covered by ACA

$0 Copay for Certain Behavioral/Mental Health Medications

Most of our plans offer a $0 copay* for inpatient and outpatient behavioral and mental health services, including certain medications from participating pharmacies.

The list of $0 copay behavioral health drugs can be found in the preface of each formulary (under $0 Behavioral Health Drug List).

*The $0 copay for behavioral/mental health services does not apply to our HDHP plans.

• Drugs that require prior authorization and step therapy:
  • for small group plan members
  • for large group plan members
• Formulary alternatives:
  • for small group plan members
  • for large group plan members

Specialty drugs are oral or injectable medications that are used to treat complex medical conditions, may require special monitoring, and may be supplied by a designated specialty pharmacy. Please read this information to help your switch to a new health plan go more smoothly.

1. If you are transitioning to a new health plan, visit your new plan’s website and check the participating specialty pharmacy network.
2. Contact your specialty pharmacy and give them your new health plan information.

If CVS/Caremark Specialty pharmacy is out -of-network for your new health plan, call your prescriber. They will need to send a new prescription for your specialty medication to your new in-network specialty pharmacy.

We have tips to help our members with asthma and diabetes lower their out-of-pocket expenses.

• Covered medications and supplies
• How to obtain your diabetic supplies

• Outpatient infusions for maintenance medications may be administered in several different settings:  in a hospital-based infusion clinic, at a provider office, at an ambulatory infusion suite, or at home.
• In many cases, outpatient infusions are less expensive for members in a provider office, at an ambulatory infusion suite, or, when feasible, at home.
• For certain infused medications, True Health New Mexico requires that members use our designated infusion partner, Optum Infusion Services. You can reach Optum Infusion Services at (505) 830-1800.
• In this Site-of-Care program, members move from the outpatient hospital infusion setting to a lower-cost and generally more convenient setting. The most appropriate site of care will vary depending upon the particular drug involved.
• True Health New Mexico is currently contracted for infusion services with Optum Infusion Services and HME Specialists, as well as a few other providers. Members can contact Customer Service for more details about contracted infusion providers.
• Below is the list of drugs currently included in the Site-of-Care Program and that must be provided by Optum Infusion Services. These infused drugs also require prior authorization for use.

Your prescription drug benefits are provided by True Health New Mexico Pharmacy Services, administered by CVS Caremark. You can contact CVS Caremark at 1-866-341-8561. True Health New Mexico requires you to use a pharmacy in the CVS Caremark network or CVS Caremark mail-order program. The CVS network includes major national and regional retail pharmacies, as well as local and independent pharmacies, throughout New Mexico and the U.S., and a specialty pharmacy called CVS Specialty Pharmacy.

True Health New Mexico provides coverage for drugs, supplies, supplements, and administration of a drug (if such services would not otherwise be excluded from coverage). The drugs must be prescribed by a licensed and qualified provider. True Health New Mexico offers a $0 copay for many generic drugs for chronic conditions such as asthma, diabetes, and depression, on most plans.

True Health New Mexico uses a preferred drug list (formulary). This is a list of prescription drugs that we cover. The formulary includes drugs for a variety of diseases and conditions. If you have questions about our formulary or your outpatient prescription drug benefits, call Customer Service at 1-844-508-4677. You’ll find more information about prescription drug limitations and exclusions in the Exclusions section of your Evidence of Coverage (Member Handbook).

True Health New Mexico partners with CVS Caremark on a program that limits initial fills of certain high-risk medications and oncology medications to two 15-day supplies. After the first two 15-day supplies are used, the full prescribed quantity will be covered at one time.

This program will work to ensure that members can tolerate these medications and may reduce potential waste.

Download the list of drugs included in the split-fill program.

This program addresses opioid overuse, which, according to the Centers for Disease Control and Prevention (CDC), is an epidemic in the U.S. You may notice restrictions on the strengths or quantities of high-potency opioid pain medications that can be dispensed at the pharmacy.

Get the facts about opioid abuse and misuse on the CDC website.

Do you need help locating an opioid treatment (buprenorphine) prescriber? Click here to locate a provider. Note: Please call Customer Service at 1-844-508-4677 to confirm that the provider you have selected is in the True Health New Mexico network.

Providers can find resources and tools on our Provider Pharmacy Resources page.