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Pharmacy

Pharmacy

Pharmacy

Beginning April 1, 2023, all Medicaid members enrolled in Amida Care will receive their prescription drugs through NYRx, the Medicaid Pharmacy Program.

Information about the transition of the pharmacy benefit from Amida Care to NYRx, the Medicaid Pharmacy Program can be found here

General information about NYRx, the Medicaid Pharmacy Program can be found HERE  along with information for members and Providers.

The NYRx preferred drug list, clinical criteria and additional program information can be found at https://newyork.fhsc.com/providers/pdp_about.asp

You may resubmit the claim with a Date of Service on or after 4/1/2023 to NYRx.

If required, providers can request prior authorization by calling the Magellan call center at 1-877-309-9493.

For situations where medically necessary and pursuant to SSL §364-j (25) and (25-a) and Section 10.32 of the Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan/Health and Recovery Model Contract, a 72-hour supply may be provided to the member.

For medications to be administered by a healthcare professional (J-codes), vaccines, and COVID-19 related drugs, please refer to the “Important Updates” section. 

 

Vaccine Coverage

Please see below for Amida Care’s Vaccine Coverage Guidelines. These coverage guidelines detail vaccine coverage for adults and children as well as which location you can receive the vaccine and which vaccines require prior authorization. You can also find updated retail pharmacy instructions for vaccine billing.

Vaccine Coverage Guidelines

Pharmacy Vaccine Billing Process

COVID-19 Information for Providers and Pharmacies 

Misc. Prior Authorization Criteria

Please see below for Amida Care’s Prior Authorization Criteria for miscellaneous agents. These coverage guidelines detail whether the specific agents mentioned will be available through either Amida Care’s pharmacy or medical benefit.

Important Updates

Physician Dispensed Drugs Policy

Non-Enrolled Provider/Pharmacy Overrides

Medication Assisted Treatment

The Amida Care Medicaid benefits plan offers members a single statewide outpatient formulary for Opioid Dependence Agents and Opioid Antagonists, in accordance with the New York State (NYS) Department of Health Single Statewide (DOH) – Medication Assisted Treatment (MAT) Formulary:

https://newyork.fhsc.com/providers/mat.asp

Please consult this list for the latest information about opioid dependence agents and opioid antagonists.

Vaccine Coverage

Please see below for Amida Care’s Vaccine Coverage Guidelines. These coverage guidelines detail vaccine coverage for adults and children as well as which location you can receive the vaccine and which vaccines require prior authorization. You can also find updated retail pharmacy instructions for vaccine billing.

J-Codes

In most instances, NDC numbers are assigned a CPT or HCPCS code. Most injectable medications begin with a “J.” It is important that claims be submitted with the most accurate information when billing for injectable medications that are administered in the office during a patient’s visit. Please see the attached list of J-Codes that require an authorization through Amida Care. Prior to administering any of the JCODES on the list below complete the prior authorization form for approval for payment.

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.

Opioid & Benzodiazipine Limits

Please consult this list for the latest information about opioid limits.

Please consult this list for the latest information about benzodiazipine limits.

 

Pharmacy Coverage Guidelines

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.

Step Therapy

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.

Quantity Limits

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.

Additional Information for Providers

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.

J-Codes:In most instances, NDC numbers are assigned a CPT or HCPCS code. Most injectable medications begin with a “J.” It is important that claims be submitted with the most accurate information when billing for injectable medications that are administered in the office during a patient’s visit. Please see the attached list of J-Codes that require an authorization through Amida Care. Prior to administering any of the JCODES on the list below complete the prior authorization form for approval for payment

Misc. Prior Authorization Criteria: Please see below for Amida Care’s Prior Authorization Criteria for miscellaneous agents. These coverage guidelines detail whether the specific agents mentioned will be available through either Amida Care’s pharmacy or medical benefit.

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.

There are two ways you can initiate a prior authorization for drugs that are handled by the Pharmacy Benefit Manager:

  1. Call Pharmacy Benefit Manager at 1-844-601-5879
  2. Fill out the form below and fax 1-877-251-5896

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 cmilan@amidacareny.org.

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