Pharmacy

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.

Transgender Drug Formulary

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

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.


Find a participating pharmacy near you.

Pharmacy-1-600x203

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:

Important Updates

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 Limits

Please consult this list for the latest information about opioid 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 mmalek@amidacareny.org.

Pharmacy Residency Information

Post-Graduate Year 1 (PGY-1) Managed Care Pharmacy Residency

As a Medicaid Special Needs Plan (SNP) in New York City, Amida Care is focused on improving the quality, value, and experience of members and providers to enrich members lives through offering a collaborative approach to value based care.

Residency Director:
Mary Malek, PharmD, AAHIVP
(646) 757 7710
mmalek@amidacareny.org
Residency Coordinator:
Kenny Ng, PharmD
(646) 757 7657
kng@amidacareny.org

Application Requirements

Applications Due: January 3, 2020

  • Required Application Documents:
    • Letter of intent summarizing candidate’s interest in managed care and qualifications
    • Current curriculum vitae
    • Mailed copy of official pharmacy school transcripts
    • Two letters of recommendation from either a:
      • Clinical rotation preceptor
      • Pharmacy employer
    • PharmD degree from an ACPE-accredited college of pharmacy
    • Active pharmacist license or eligibility for licensure in the state of New York
    • Baseline knowledge and understanding of HIV testing, diagnosis and treatment
    • Excellent written and verbal communication skills in English
    • Strong knowledge of Microsoft Office (Word and Excel)
    • Demonstrate understanding and sensitivity to multi-cultural values, beliefs, and attitudes of internal and external contacts
    • Demonstrate appropriate behaviors in accordance with the organization’s vision, mission, and values

    How to Apply: Please submit required documentation to mmalek@amidacareny.org. References are to submit letters of recommendation directly as well. Please have official transcripts mailed to:

    Mary Malek
    14 Penn Plaza, 3rd floor
    New York, NY 10122

    About the Program

    This PGY-1 Managed Care residency will equip the resident to participate as a member of an interdisciplinary managed healthcare team to apply and guide population-level patient care encounters. As a SNP, Amida Care specializes in coordinating care for chronic conditions including people living with HIV/AIDS and behavior health disorders. Amida Care also services people of the transgender experience or those experiencing homelessness, regardless of HIV status. The resident will have a unique opportunity to directly assist in the End the HIV Epidemic Initiative, and also work to improve transgender healthcare throughout the program.

    Program Areas

    At a minimum the resident will be expected to participate in the following areas:

    Utilization Management (UM)

    • Develop and present quarterly Drug Utilization Reviews (DUR)
    • Develop clinical policies
    • Routinely participate in UM and the prior authorization (PA) processes
    • Evaluate specialty pharmacy management

    Formulary Management

    • Coordinate and participate in quarterly Pharmacy and Therapeutics (P&T) Committee meetings
    • Develop clinical monograph for presentation at P&T Committee meetings
    • Investigate and review cases for Fraud Waste and Abuse

    Quality Programs

    • Participate in corporate quality improvement activities
    • Coordinate at least one performance improvement plan
    • Engage in pharmacy quality initiatives

    Pharmacy Benefit Management

    • Managed Care Pharmacy Operations
    • Account Management and Benefit Design
    • Pharmacy Network Management
    • Routine interaction and engagement with PBM Account Management Team
    • Complaint management and tracking

    Clinical Programs

    • Medication Therapy Management
    • Drug Information
    • Develop and participate in Interdepartmental Clinical Initiatives
    • Develop and implement strategies to address/improve the quality of care as measured (HEDIS/QARR)
    • Health Outcome Research
    • Complete a research project for presentation at the annual Academy of Managed Care Pharmacy (AMCP) Conference

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