Medicaid Pharmacy Program
Important Information About Your Family Health Plus
Prescription Drug Benefit
Dear Family Health Plus Member:
The prescription drug benefit under the Family Health Plus program will be administered through the Medicaid Program rather than your health plan as of October 1, 2008. Drugs covered under the Family Health Plus program will continue to be covered; however some may require prior authorization.
Pharmacy benefits include:
- Prescription drugs
- Insulin and diabetic supplies currently 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
Here's what you need to know about the change:
- Beginning October 1, 2008, you must use a NYS Benefit Identification Card to obtain your pharmacy benefit. This is what your card will look like.
- If you do not already have a Benefit Identification Card, one will be mailed to you shortly in a separate envelope. If you are already using a Benefit Identification Card to obtain other benefits, such as Food Stamps, you must use this same Benefit Identification Card to access your pharmacy benefits beginning October 1, 2008.
- If you have lost or damaged your Benefit Identification Card, you can get a new one from your county Department of Social Services. In NYC enrollees can replace a lost or damaged Benefit Identification Card by calling the HRA Infoline at 1-877-472-8411.
- Your drug co-payment will not change.
- You must use a pharmacy that accepts Medicaid. Check with your current pharmacy to see if they accept Medicaid. If they do not, you will need to obtain new prescriptions to take to another pharmacy that accepts Medicaid.
- Ask your pharmacist if your drugs are covered my Medicaid. If not, your doctor may need to prescribe another drug. Your doctor may need to request a prior authorization for some drugs to be covered by Medicaid.
Reminder: This change only affects your pharmacy benefit. You must still use your health plan card to get your other Family Health Plus health benefits.
For questions about this change, you may also call the Medicaid Helpline at 1-800-541-2831 from 9am through 5pm, Monday through Friday. If you have questions about your prescriptions, speak with your pharmacist.
The law that requires us to make this change is Chapter 58 of the Laws of 2008 which added a new section, 369-ee (2-b), amended Section 367-a (7) (d) of that law, and amended the Public Health Law, Section 270 (11). If you wish, you can have a meeting (conference) to talk about this action, or you can ask for a "State Fair Hearing."
You have the right to request an appeal if you think the law does not apply to you or if you think we do not have the right information about you. If you ask for an appeal because you think the law is wrong, your appeal will be decided without a hearing. If you want to appeal this action, please read the section in this letter that says, "RIGHT TO A CONFERENCE OR FAIR HEARING."
Sincerely,
Deborah Bachrach
Deputy Commissioner
Office of Health Insurance Programs
Enclosure
RIGHT TO A CONFERENCE OR FAIR HEARING
RIGHT TO A CONFERENCE: You may have a conference to review this action. If you want a conference you should ask for one as soon as you can. At the conference, if we find that we took the wrong action or if you give us new facts that cause us to change our decision, we will give you a new notice. You may ask for a conference by calling or sending a written request to your local social services department. If you ask for a conference you are still entitled to a fair hearing. If you want to have your benefits continue unchanged (aid continuing) until you get a fair hearing decision, you must request a fair hearing in the way described below. Read below for fair hearing information.
RIGHT TO A FAIR HEARING: These changes in your Medical Assistance coverage are based on changes in state law and policy. You have a right to a fair hearing if you think we made a mistake, but not just because you think the new law or policy is unfair. The hearing officer at the hearing may decide that you do not have a right to a hearing if the only issue at the hearing is the change in law or policy.
If you live anywhere in New York State, you may request a Fair Hearing by telephone, fax, online or by writing to the address below.
Telephone: Statewide toll-free request number is 800-342-3334. Please have this notice with you when you call.
Online: Complete online request form at http://www.otda.state.ny.us/oah/forms.asp
In Writing: Fill in the space below and send a copy of this notice to:
Fair Hearing Section
NYS Office of Temporary and Disability Assistance
Fair Hearings
P.O. Box 1930
Albany, New York 12201-1930 Please keep a copy for yourself
Fax: Send a copy of this notice to (518) 473-6735
If you live in NYC, you may also make your request in person by walking into the offices listed below.
Walk-In (NYC ONLY): Bring a copy of this notice to the Office of Administrative Hearings, of the Office of Temporary & Disability Assistance, 14 Boerum Place, Brooklyn, New York, or 330 W. 34th Street, 3rd Fl., New York, NY.
I want a Fair hearing. This action is wrong because_______________________________________________________________________
________________________________________________________________________________________________________________
Client Signature:___________________________________________Client print name here:_____________________________________
Client Address:____________________________________________________________________________________________________
Phone Number:_____________________________Case Number:__________________________CIN Number:_______________________
YOU HAVE 60 DAYS FROM THE DATE OF THIS NOTICE TO REQUEST A FAIR HEARING
If you request a fair hearing, the State will send you a notice informing you of the time and place of the hearing. You have the right to be represented by legal counsel, a relative, a friend or other person, or to represent yourself. At the hearing you, your attorney or other representative will have the opportunity to present written and oral evidence to demonstrate why the action should not be taken, as well as an opportunity to question any persons who appear at the hearing. Also, you have the right to bring witnesses to speak in your favor. You should bring to the hearing any documents such as this notice, pay stubs, receipts, medical bills, heating bills, medical verification, letters, etc. that may be helpful in presenting your case.
CONTINUING YOUR BENEFITS:
If you request a fair hearing before the effective date stated in this notice, you will continue to receive your benefits unchanged under certain circumstances. Your benefits will not be continued pending the appeal decision when the sole issue is the change in the law. If the appeal is for other reasons, such as the application of the law to your situation, or if there is another factual issue, then your benefits will be continued pending the decision. However, if you lose the fair hearing, we may recover the cost of any Medical Assistance benefits that you should not have received. If you want to avoid this possibility, check the box below to indicate that you do not want your aid continued, and send this page along with your hearing request. If you do check the box, the action described above will be taken on the effective date listed above.
I agree to have the action taken on my Medical Assistance benefits, as described in this notice, prior to the issuance of the fair hearing decision.
LEGAL ASSISTANCE:
If you need free legal assistance, you may be able to obtain such assistance by contacting your local Legal Aid Society or other legal advocate group. You may locate the nearest Legal Aid Society or advocate group by checking your Yellow Pages under "Lawyers".
ACCESS TO YOUR FILE AND COPIES OF DOCUMENTS:
To help you get ready for the hearing, you have a right to look at your case file. If you call or write to us, we will provide you with free copies of the documents from your file, which we will give to the hearing officer at the fair hearing. Also, if you call or write to us, we will provide you with free copies of other documents from your file, which you think you may need to prepare for your fair hearing. To ask for documents or to find out how to look at your file, contact your local Department of Social Services or, in NYC, contact the NYC Human Resources Administration. If you need help to get the phone number or address of your local Department of Social Services office or the NYC Human Resources Administration, call the NYS Medicaid Hotline at 1-800-541-2831.
If you want copies of documents from your case file, you should ask for them ahead of time. They will be provided to you within a reasonable time before the date of the hearing. Documents will be mailed to you only if you specifically ask that they be mailed.
FOR MORE INFORMATION ON YOUR CASE: If you want to see your file, to find out how to ask for a Fair Hearing or to find out how to ask for copies of your file, contact your local Department of Social Services or, in NYC, contact the NYC Human Resources Administration.