Pharmacy Carve-Out: Member Notice of Change

ATTENTION: MEDICAID MANAGED CARE BENEFICIARIES

CHANGES TO BE MADE TO YOUR MEDICAID PHARMACY BENEFITS
EFFECTIVE April 1, 2021

This notice tells you about this upcoming change Please read this notice carefully and save it for future reference. You can also access this notice here.

PHARMACY BENEFIT CHANGE:

  • Starting April 1, 2021, your prescriptions will not be covered by [Each Managed Care Plan will insert their Plan name]. They will be covered by Medicaid Fee for Service.
  • Most pharmacies in New York State take Medicaid Fee for Service. If your pharmacy does not take Medicaid Fee for Service, you may:
    • Ask your doctor to send a new prescription to a pharmacy that takes Medicaid Fee for Service, or
    • Ask your pharmacist to transfer a refill to a pharmacy that takes Medicaid Fee for Service.
    • Locate a pharmacy that takes Medicaid Fee for Service here.
      Note: The link to the pharmacy locator tool is not yet active and will be active in early February 2021.
  • You will need to show your pharmacist either your Medicaid Card or your Health Plan Card. This will tell them your Client Identification Number (CIN).
    • Your Medicaid Card looks like this, and your CIN is highlighted:
Medicaid Card
  • Your Health Plan Card looks like this, and the location of the CIN is highlighted:

[Each Managed Care Plan will insert a picture of their ID card,
highlighting the location of the Client Identification Number.]

  • Medicaid Fee for Service has a list of covered drugs. Over-the-counter drugs and most drugs are on the list. This list of covered drugs can be found here.
    • Some drugs need prior approval before they can be filled. This list will tell you if a drug needs prior approval. Your doctor will call to get prior approval.
    • If your drug is not on this list:
      • Your doctor can ask Medicaid for approval to let you get the drug, or
      • Your pharmacist can talk to your doctor about changing to a drug that is on the list.
  • Medicaid Fee for Service also has a preferred drug list. This list can be found here
    • If you need a drug that is listed as a non-preferred drug, you will be able to get a one-time only fill of this drug from April 1, 2021, through June 30, 2021.
    • If you need a non-preferred drug, please contact your pharmacist or doctor so that they can get approval for you to get this drug.
  • The Medicaid copayment structure is not changing. Your copayment might change depending on if the drug is preferred or non-preferred.
  • Your pharmacy benefit also covers certain supplies:
    • A list of covered supplies can be found in the Medicaid Pharmacy Manual here.
      • Note: you will need to click on "OTC and Supply Fee Schedule."
    • A list of preferred diabetic meters and test strips can be found here.
      • Medicaid will allow a one-time only fill from April 1, 2021 through June 30, 2021 for non-preferred test strips.
      • You will need to change to a preferred diabetic meter and test strip.

Do you have questions or need help? The Medicaid Helpline can assist you. They can talk to you in your preferred language. They can be reached at 1-855-648-1909. They can answer your call:

  • Monday - Friday, 8 am – 8pm
  • Saturday, 9am – 1 pm

If you would like to request supporting aids, services, materials or other information regarding this change in an alternative format or larger print, call the number on your health plan card.