Covered Drugs (Formulary)
Amida Care has a list of covered prescription medications called a formulary. Our formulary includes all of the medications that are covered by Medicaid and available for use by Amida Care members.
See how Amida Care’s formulary compares to formularies of other plans.
Find a participating pharmacy near you.
As of October 1, 2016, Walgreens/Duane Reade has joined our network and offers many HIV specialty locations in all five boroughs of New York City.
Specialized pharmacies by borough:
Behavioral Health Carve-in Benefit
As of October 1, 2015, the Amida Care Medicaid benefits plan offers members additional access to certain Injectable Behavioral Health medications as part of the Qualified Health Plan (QHP). See this chart for important updates.
Please consult this list for the latest information about opioid limits.
Prior Authorization Criteria
For certain drugs, you or your provider need to get approval from the Plan before we agree to cover the drug for you. This is called prior authorization. Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the Plan. See Coverage Guidelines for the list of medications that require prior authorizations.
This requirement encourages you to try an effective drug that is less costly before the Plan covers another drug. For example, if Drug A and Drug B treat the same medical conditions, the Plan may require you to try Drug A first. If Drug A does not work for you, then the Plan will cover Drug B. This requirement to try a different drug first is called step therapy. See Coverage Guidelines for the list of medications that require step therapy.
For certain drugs, the Plan limits the amount of the drug that will be covered. These plan limits are called quantity limits. See Coverage Guidelines for the list of medications that have quantity limits.
Prior Authorization and Forms
Please note: For any HIV regimen changes or rejection, providers can call 646-757-7979.
Initiating Prior Authorization
The General Request Form can be used to initiate a Prior Authorization for medication. Depending on the medication requested, there are additional forms available that can also be used to ensure that required information is received.
Authorizations reviewed by Amida Care: The prior authorization request forms below will be reviewed by Amida Care. Once the form is completed, it can be faxed to Amida Care at 646-786-0997. Please be sure to include ALL relevant information needed for the request, as missing information will lead to delays in prior authorization. Amida Care may contact you via fax or phone if additional information is needed to complete the request.
- Hepatitis C
- Long Acting Injectable Antipsychotic
- Methadone – New Starts
- Methadone QL Exception
Authorizations reviewed by ESI: Please use the appropriate forms below in order to expedite the process. Once the form is completed, it can be faxed to the Pharmacy Benefit Manager at 888-235-8551. Please be sure to include ALL relevant information needed for the request, as missing information will lead to delays in prior authorization. Express Scripts may contact you via fax or phone if additional information is needed to complete the request.
- General Request Form
- Cross Gender Hormone Therapy
- Enteral Product
- Proton Pump Inhibitor
There are two ways you can initiate a prior authorization for drugs that are handled by the Pharmacy Benefit Manager:
- Call Pharmacy Benefit Manager at 1-800-735-2851, option 2
- Fill out the form below and fax 1-888-235-8551
Pharmacy and Therapeutics Committee
The Amida Care Pharmacy and Therapeutics Committee is an advisory group that meets quarterly to discuss issues regarding drug therapy that address the concerns of both members and providers. Please contact the Director of Pharmacy for any feedback or suggestions you may have at email@example.com.