Posted 10/1/2020 at 1:09 PMLearn more about this change
Beginning April 1, 2021 instructed by the New York State Department of Health (NYS DOH), Medicaid Managed Care (MMC) plans will be moving the pharmacy benefit into the New York State Fee-for-Service (FFS) program. NYS DOH requires MMCs to align with their formularies by October 1, 2020. As required by the DOH, the following categories are subject to plan exclusions:
- Drug(s)/Classes excluded per policy, state plan amendment, and/or state or federal legislation
- Agents when used to promote fertility*
- Agents when used for cosmetic purposes or hair growth
- Agents when used for anorexia, weight loss, or weight gain
- Agents when used for the treatment of sexual or erectile dysfunction*
- Agents when used for the symptomatic relief of cough and colds*
- Prescription vitamins and mineral products*
- Non-prescription drugs (OTC)*
- Prescription drugs not included in the Federal Rebate Program
- Drugs classified as DESI (drug efficacy study implementation) that have not been proven to be effective by the FDA
- Physician administered drugs (will be transitioned to medical benefit)
- Medicaid pharmacy benefits
*Certain exceptions may apply.
These changes may require a shift to a drug on the preferred drug list.
We request that you advise Healthfirst members to use drugs on the Healthfirst preferred drug list whenever clinically appropriate. Updated formularies are available here. The DOH resources provide specific drug codes for what is covered.
If you have questions, please call Customer Care: Medicaid members call 1-855-298-2485 (TTY 1-800-863-5488); Personal Wellness Plan members call 1-888-790-4272 (TTY 1-800-863-5488). Hours of operation are 24 hours a day, 7 days a week.
NYS DOH resources: