Family Health Plus Pharmacy Benefit Notice for Pharmacists

August 1, 2008

Dear Pharmacy Provider:

Effective October 1, 2008, Family Health Plus enrollees will obtain their pharmacy benefit through the Medicaid fee-for-service program. Family Health Plus enrollees will receive a Medicaid Benefit Identification Card to obtain their pharmacy benefit.

Pharmacy benefits available for Family Health Plus enrollees by prescription or fiscal order include:

  • Prescription Drugs
  • Insulin and diabetes supplies covered as a pharmacy benefit by Medicaid (e.g., insulin syringes, blood glucose test strips, lancets, alcohol swabs)
  • Smoking cessation agents, including over-the-counter (OTC) products
  • Select over-the-counter medications covered on the Medicaid Preferred Drug List (Prilosec OTC, loratadine, Zyrtec)
  • Hearing aid batteries
  • Enteral formulae, with prior authorization (1-866-211-1736)

Prescriptions will be subject to all Medicaid requirements. For your information, enclosed is a summary of Medicaid's pharmacy management programs.

Prescriptions originally filled and reimbursed under a Family Health Plus managed care plan may continue to be filled under Medicaid. However, if the prescription has already been filled 5 or more times or is older than 180 days from the date written, a new prescription will be required. All controlled substance laws apply.

Prescriptions for drugs not contained on the New York State List of Medicaid Reimburseable Drugs will not be reimburseable, even if they were originally covered by the managed care plan. Prescriptions drugs not covered by Medicaid cannot be billed to the managed care plan.

Prescription drug co-payments for Family Health Plus enrollees will not change. Co-payments will remain at $6.00 for brand-name drugs, $3.00 for generic drugs, $1.00 for diabetic supplies, hearing aid batteries and enteral formulae, and $0.50 for select over-the-counter drugs.

Please note that until October 1, 2008, Family Health Plus enrollees will continue to receive their prescription drug benefit through their managed care plan. If you have billing questions, please contact Computer Sciences Corporation at (800) 343-9000. Questions regarding Medicaid pharmacy policy can be directed to my office at (518) 486-3209.

Sincerely,

Linda J. Jones, R.N., Director
Bureau of Pharmacy Policy and Operations
Office of Health Insurance Programs