The Medicaid Pharmacy Benefit

Medicaid’s pharmacy benefit was moved into the Medicaid managed care benefit package in October of 2011.  Before that date, people enrolled in a Medicaid managed care plan obtained all of their health care through the plan, but used their regular Medicaid card to access any drug available on the state formulary on a "fee for service" basis without needing to utilize a restricted pharmacy network or comply with managed care plan rules. 

DUAL ELIGIBLES -- Note that Medicaid generally does NOT cover prescription drugs for dual eligibles - that is, individuals who have both Medicaid AND Medicare.  These individuals are expected to get their prescription drugs covered through Medicare Part D. 

HOW WILL MANAGED CARE CHANGE THE PHARMACY BENEFIT FOR CONSUMERS?  The Medicaid pharmacy benefit includes all FDA approved prescription drugs, as well as some over-the-counter drugs and medical supplies.   Under Medicaid managed care:

CAN CONSUMERS SWITCH PLANS IN ORDER TO GAIN ACCESS TO DRUGS?

Changing plans is often an effective strategy for consumers eligible for both Medicaid and Medicare (dual eligibles) who receive their pharmacy service through Medicare Part D, because dual eligibles are allowed to switch plans at any time. Medicaid consumers will have this option only in the limited circumstances during the first year of enrollment in managed care. 

STEPS CONSUMERS CAN TAKE WHEN A MANAGED CARE PLAM DENIES ACCESS TO A NECESSARY DRUG

As a first step, consumers should try to work with their providers to satisfy plan requirements for prior authorization or step therapy or any other utilization control requirements.  If the plan still denies access, consumers can pursue review processes specific to managed care while at the same time pursuing a fair hearing.

Enrollees who are in the first 90 days of enrollment, or past the first 12 months of enrollment also have the option of switching plans to improve access to their medications.

Consumers who experience problems with access to prescription drugs should always file a complaint with the State Department of Health’s Managed Care Hotline, number listed below. 

ACCESSING MEDICAID'S PHARMACY BENEFIT IN FEE FOR SERVICE MEDICAID

For those Medicaid recipients who are not yet in a Medicaid Managed Care program, and who do not have Medicare Part D, the Medicaid Pharmacy program  covers most of their prescription drugs and select non-prescription drugs and medical supplies for Family Health Plus enrollees.  Certain drugs/drug categories require the prescribers to obtain prior authorization.  These include brand name drugs that have a generic alternative under New York's mandatory generic drug program or prescribed drugs that are not on New York's preferred drug list.  The full Medicaid formulary can be searched on the eMedNY website.

Even in fee for service Medicaid, prescribers must obtain prior authorization before prescribing non-preferred drugs unless otherwise indicated. Prior authorization is required for original prescriptions, not refills. A prior authorization is effective for the original dispensing and up to five refills of that prescription within the next six months. Click here for more information on NY's prior authorization process.

The New York State Board of Pharmacy publishes an annual list of the 150 most frequently prescribed drugs, in the most common quantities. The State Department of Health collects retail price information on these drugs from pharmacies that participate in the Medicaid program. Click here to search for a specific drug from the most frequently prescribed drug list and this site can also provide you with the locations of pharmacies that provide this drug as well as their costs. 
Click here to view New York State Medicaid’s Pharmacy Provider Manual. 

WHO YOU CAN CALL FOR HELP

Community Health Advocates Hotline:   1-888-614-5400

NY State Department of Health's Managed Care Hotline:  1-800-206-8125  (Mon. - Fri. 8:30 am - 4:30 pm)

NY State Department of Insurance: 1-800-400-8882

NY State Attorney General's Health Care Bureau: 1-800-771-7755



Article ID: 91
Last updated: 15 Nov, 2013
Revision: 6
Medicaid -> Other Services -> The Medicaid Pharmacy Benefit
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