Family Health Plus Pharmacy Benefit Notice for Providers

August 1, 2008

Dear Provider:

Effective October 1, 2008, Family Health Plus enrollees will obtain their pharmacy benefit through the Medicaid fee-for-service program. Drugs administered by practitioners in their offices (J-Code drugs) will continue to be billed as a medical benefit to the Family Health Plus plan.

Pharmacy benefits available 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, including prior authorization of drugs. Some Family Health Plus managed care enrollees may currently be patients of pharmacies not enrolled in the Medicaid fee-for-service program and will need to change pharmacies in order to obtain their medications. If an enrollee's (non-controlled) 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. These patients may contact you for new prescriptions or for assistance with prior authorization requirements.

Prescriptions for Family Health Plus enrollees will be subject to all Medicaid Pharmacy management programs including the Preferred Drug Program, Clinical Drug Review Program, and the Mandatory Generic Drug Program (see the enclosed program descriptions). Please contact the Medicaid Pharmacy Prior Authorization Clinical Call Center at (877) 309-9493 for information about these programs. Information is also available at https://newyork.fhsc.com or http://www.nyhealth.gov/health_care/medicaid/program/pharmacy.htm

Please note that until October 1, 2008, Family Health Plus enrollees will continue to obtain their prescription drug benefit through their managed care plan. If you have questions regarding this information, please contact my office at (518) 486-3209 for assistance.

Sincerely,

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