Pharmacy Benefits for Medicaid, Family Health Plus and Child Health Plus

Since October 1, 2011, pharmacy benefits for Medicaid and Family Health Plus members have been covered by Neighborhood Health Providers (NHP) and Suffolk Health Plan (SHP) through Express Scripts.

EFFECTIVE APRIL 1, 2012, PHARMACY BENEFITS FOR CHILD HEALTH PLUS ARE COVERED THROUGH EXPRESS SCRIPTS (previously covered through CVS/CAREMARK).

Child Health Plus members will receive a new NHP or SHP ID card with Express Scripts printed on the card. Members will use this new ID card to get their prescriptions and to access health care services. Child Health Plus benefits remain the same: prescription drugs are covered, but there is no coverage for over-the-counter medications (OTCs) or disposable supplies (other than diabetic supplies), and there are no co-payments. Clotting factors are not covered for outpatient administration.

EXPRESS SCRIPTS

Express Scripts has an extensive pharmacy network. Members must fill their prescriptions at a network pharmacy. Please note that since December 1, 2011, pharmacies owned and/or operated by Walgreens (Walgreens, Duane Reade, Happy Harry’s and OptionCare) are no longer part of the Express Scripts pharmacy network. Members who have filled prescriptions at any of those pharmacies and who have refills remaining may have their prescriptions transferred to an Express Scripts network pharmacy by calling the new pharmacy and asking them to have their prescription transferred from the Walgreens-affiliated pharmacy. As an alternative, the prescriber can call the new pharmacy with the prescription information.

There are several important policies and procedures to keep in mind:

• Formulary
  NHP/SHP has its own formulary. For a full searchable formulary listing all covered medications and medical supplies, click here. For a list of formulary alternatives to commonly prescribed non-formulary medications, click here.
  
  

• Quantity Limits

  Almost all medications are dispensed as a 30-day supply (except for: 60-90 days for certain estrogen replacement products; 90 days for Boniva IV; and contraceptive injections that last for 90 days). Several medications have specific quantity limits. If the medication has a “QLL” indication on the formulary, these quantity limits apply. Please click here for a list of these medications.
  
  
• Medical Supplies
  NHP/SHP is responsible for covered medical supplies for the Medicaid and Family Health Plus programs, and for diabetic supplies for the Child Health Plus program. A list of covered supplies can be found here. Prescriptions for supplies will be honored at Express Scripts network pharmacies. Supplies, including diabetic test strips, may also be obtained through participating durable medical equipment (DME) vendors. DME items will NOT be dispensed by pharmacies and MUST be ordered through NHP/SHP participating vendors. Some of these items require prior authorization.
  
  
• Prior Authorization
  Some of your patients’ medications may not be covered, or may require a Prior Authorization. Call Express Scripts at 1-800-287-0358 or fax the Prior Authorization form to 1-800-357-9577. Please be prepared to submit concise clinical information, including the diagnosis, previous treatment if any, and the rationale for why the prescribed medication is more appropriate than an alternative on the formulary.
  
  
• Step Therapy
  Some medications require step therapy. The Express Scripts claims system will automatically look back 130 days for a first-step prescription; if one or more first step medication was dispensed, the second step medication will be covered.
  
  
• Grandfathered Medications
  Some Medicaid and Family Health Plus members are able to continue receiving the medications they were on before October 1, 2011, even if the medications are not on the NHP/SHP formulary – see the list of “grandfathered” medications. Some members of Child Health Plus will also be able to continue the medications they were on prior to April 1, 2012.
  
  
• Clinical Drug Review Program
  Members who were on drugs approved by Medicaid’s Clinical Drug Review Program (CDRP) were able to continue their medications for up to 90 days in most cases. Since that period of time has expired, prior authorization is required to continue these medications.
  
  
• Specialty Drugs
  NHP/SHP will provide "specialty" medications through Express Scripts' specialty pharmacy, CuraScript (see the list of covered medications). Members on these "specialty drugs" will be able to get up to two refills at their local pharmacy, but must transition to receiving their medication from CuraScript. Members using other specialty pharmacies must switch to CuraScript. Members on specialty drugs and prescribers of these drugs will be contacted by CuraScript. There are specific referral forms for several conditions and medications - click here for those forms or use the Prescription Enrollment Form for all other drugs. Selected medications can be filled at an Express Scripts retail pharmacy in urgent situations. Many specialty drugs require Prior Authorization – click here for the list. Call CuraScript at 1-888-773-7376, or fax forms to 1-888-773-7386.
  
  
• Synagis® (Palivizumab) for Prophylaxis of RSV Infection
  NHP/SHP follows the NYS Department of Health guidelines for dispensing Synagis® (Palivizumab) for prophylaxis of respiratory syncytial virus (RSV) infection in certain high risk infants and children with a history of prematurity. Synagis® became eligible for coverage as of October 15, 2011. (If the NYS Department of Health extends the Synagis® “season” beyond the expected March 31 end date, prescribers will have to obtain prior authorization for any additional doses.) Synagis® must be ordered from CuraScript; complete the Synagis Enrollment Form and fax it to CuraScript at 1-866-297-0934. This medication may be given at home if needed, but home care services require prior authorization by NHP/SHP Care Coordination – call 1-800-765-3805.
  
  
• Human Growth Hormone
  NHP/SHP requires that documentation be on file for each patient certifying that the Human Growth Hormone (HGH) product was prescribed for an FDA approved indication before HGH prescriptions can be dispensed. CuraScript Specialty Pharmacy will contact the prescribing physician to obtain specific documentation of a prescriber’s certification of an approved FDA indication for the HGH. Click here for a document with FAQs and the Prescriber Certification Form.
  
  
• Co-Payments
  Medicaid and Family Health Plus member co-payments for drugs have not changed, except that there are no co-payments for medical and diabetic supplies, enteral formulas and hearing aid batteries for Medicaid members. The Child Health Plus program continues to have no co-payments.
  
  
• Enteral Formulas
  Please note that as per NYS Medicaid benefit changes effective April 1, 2011, enteral formulas are restricted to specific subsets of patients (see clinical guidelines). NHP/SHP requires Prior Authorization for these products. Enteral formula can be provided as a pharmacy benefit (contact Express Scripts for Prior Authorization at 1-800-287-0358) or through an NHP/SHP-participating DME vendor. Call NHP/SHP for prior authorization at 1-800-765-3805. For Child Health Plus, there is a $2500 annual benefit limitation for modified solid food products for treatment of certain inherited disease of amino acid and organic acid metabolism.

You may request prior authorization or an exception to any of our formulary/step therapy/quantity limit rules by calling Express Scripts at 1-800-287-0358 or by faxing the Prior Authorization form to 1-800-357-9577. Your request will be reviewed against NHP/SHP-approved guidelines based on FDA indications and the peer-reviewed medical literature. Members have internal appeal, external appeal and fair hearing rights (Medicaid and Family Health Plus only) if a denial is issued. Denials will only be issued by a physician, and all appeals are reviewed by a medical director at NHP/SHP.

If you have any questions about pharmacy benefits, please call Provider Services:

• NHP Provider Services 1-800-558-7970
• SHP Provider Services 1-877-747-6789

To contact Express Scripts customer service, please call:

• 1-877-782-8655

The following drugs are covered by Medicaid fee-for-service:

1. Hemophilia blood factors, whether furnished or administered as part of a clinic or office visit or administered during a home care visit – for Medicaid and Family Health Plus enrollees; and

2. Risperidone microspheres (Risperdal® Consta®), paliperidone palmitate (Invega® Sustenna®), and olanzapine (Zyprexa® Relprevv™) when administered to Medicaid SSI and SSI-related enrollees.