Once again, in April 2023, NYS changed the way people without Medicare access prescription drugs. These are people in "mainstream" Medicaid managed care plans, including HARP and HIV-SNP plans. These changes were delayed from 2021, but are in effect as of April 1, 2023. These were enacted under the SFY 2021-22 budget agreement.
HOW DID PEOPLE IN MAINSTREAM MANAGED CARE PLANS GET PRESCRIPTIONS BEFORE APRIL 1, 2023?
Since October 2011, most people who do not have Medicare obtained their drugs through their Medicaid managed care plan. In 2011, this drug benefit was "carved into" the Medicaid managed care benefit package.
As of April 2023 - In the NYS Budget enacted in April 2020, the pharmacy benefit was "carved out" of "mainstream" Medicaid managed care plans. That means that members of managed care plans now access their drugs outside their plan from NYRx - the new NYS Medicaid Pharmacy Program. This is a change from how they access the rest of their medical care, which is accessed from in-network providers. The Budget enacted in April 2021 delayed this transition for 2 years until April 2023.
INFORMATION ON THE APRIL 2023 CHANGE in PRESCRIPTION ACCESS FOR MEDICAID MANAGED CARE MEMBERS
HOTLINE to CALL FOR HELP and REPORT PROBLEMS
Member Materials from Advocacy Organizations
NYS Medicaid Pharmacy Program (NYRx) homepage --
NYS Dept. of Health Medicaid Updates for providers
How Prescription Drugs were Previously Obtained through Managed Care Plans - (Until April 2023)
HOW DO MANAGED CARE PLANS DEFINE 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.
The enrollee must first request an internal Plan Appeal and wait for the Plan's decision. An adverse decision is called a 'Final Adverse Determination" or FAD. See model Denial FAD Notice and FAD Notice to Reduce, Suspend or Stop Services. The enroll has the right to request a fair hearing to appeal an FAD. The enrollee may only request a fair hearing BEFORE receiving the FAD if the plan fails to send the FAD in the required time limit, which is 30 calendar days in standard appeals, and 72 hours in expedited appeals. The plan may extend the time to decide both standard and expedited appeals by up to 14 days if more information is needed and it is in the enrollee's interest.
AID CONTINUING -- If an enrollee requests a Plan Appeal and then a fair hearing because access to a drug has been reduced or terminated, the enrollee has the right to aid continuing (continued access to the drug in question) while waiting for the Plan Appeal and then the fair hearing. The enrollee must request the Plan Appeal and then the Fair Hearing before the effective date of the IAD and FAD notices, which is a very short time - only 10 days including mailing time. See more about the changes in Managed Care appeals here. Even though that article is focused on Managed Long Term Care, the new appeals requirements also apply to Mainstream Medicaid managed care.
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
DOH Official Helpline for Pharmacy Rx NYRx@health.ny.gov. and NYS DOH Medicaid Helpline : 1-855-648-1909. TTY 1-800-662-1220
NY State Attorney General's Health Care Bureau: 1-800-771-7755