Don’t Lose Your Medicaid Benefits - Act Now
Don’t Lose Your Medicaid Benefits - Act Now

Pharmacy

Pharmacy

Amida Care Medicaid 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.

Additional Information for Providers

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.

 

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