Pharmacy

Pharmacy Claims Processing

Important Pharmacy Claims Processing Change beginning January 1, 2024

Express Scripts Transition: Frequently Asked Questions

NH Healthy Families is committed to providing appropriate, high-quality, and cost-effective drug therapy to all NH Healthy Families members. NH Healthy Families covers prescription and certain over-the-counter medications with a written order from a NH Healthy Families provider. Not all medications are covered by the pharmacy program. Some medications may require prior authorization or may have age, dosage or quantity limitations. Please use the below Preferred Drug List to find more information on the drugs that are covered

NH Healthy Families Preferred Drug List (PDF)

Machine-Readable File (JSON)

Members have the option to receive a 90-day supply of their maintenance medications at in-network pharmacies.

NH Healthy Families also has in network mail-order pharmacies available to our membership to ensure timely delivery of medications. For additional information please reach out to NH Healthy Families at 866-769-3085, Monday through Friday 8 a.m. to 5 p.m.

Prior Authorization Criteria

NH Healthy Families Medical and Pharmacy Policies.

NH Healthy Families Prescription Prior Authorization FAQ’s (PDF).

Medication Requests

Submit a secure electronic Prior Authorization request for any of the below forms through Cover My Meds here.

Pharmacy Services processes pharmacy claims for self-administered (i.e. oral, self-injectable, topical, ophthalmic) drugs. For self-administered medications, submit a secure electronic Prior Authorization request through Cover My Meds here or use the medication request form(s) below:

Provider Help Desk:

1-877-250-5227

NH Healthy Families Oncology Management Program

NH Healthy Families is pleased to collaborate with New Century Health (NCH), an oncology quality management company, to implement a new oncology pre-approval program, NH Healthy Families Oncology Pathway Solutions. The program simplifies the administrative process for providers to support the effective delivery of quality patient care.

As of May 1, 2020, all oncology-related chemotherapeutic drugs and supportive agents require clinical review by NCH before being administered in a physician’s office, outpatient hospital or ambulatory setting. This prior authorization requirement applies to both pharmacy dispensed and office administered medication requests for all NH Healthy Families Medicaid members.

NH Healthy Families Oncology Pathway Solutions program benefits include:

  • The use of clinical criteria, based on nationally-recognized guidelines, to promote evidence-based cancer care.
  • Increased collaboration with physician offices to foster a team approach.
  • Peer-to-peer discussions with medical oncologists who can understand and better discuss treatment plans.
  • A provider web portal to:
    • Obtain real-time approvals when selecting evidence-based NCH treatment care pathways.
    • Determine which clinical documentation is necessary for medical necessity review.
    • View all submitted requests for authorization in one location.
    • Check member eligibility.

Pre-approval Process

  • The requesting physician must complete an authorization request using one of the following methods:

Pharmacy Policy and Formulary Changes