Medicaid Redesign Team Changes Effective
July 1, 2013

Date Issued: 7/1/2013

Prescriber Prevails

Effective July 1, 2013, Medicaid managed care and Family Health Plus plans cover prescription drugs in the therapeutic classes listed below, including non-formulary drugs, when the prescriber demonstrates to EmblemHealth that such drugs in the prescriber's reasonable professional judgment are medically necessary and warranted.

  • Anti-depressant
  • Anti-psychotic
  • Anti-retroviral
  • Anti-rejection
  • Epilepsy, seizure
  • Endocrine
  • Hematologic
  • Immunologic

Note: Prior approval may still be necessary for these medications (see the Care Management chapter of the Provider Manual). The burden is on the prescriber to demonstrate medical necessity.

PCI Angioplasty

As of July 1, 2013, Medicaid managed care and Family Health Plus plans limit coverage of percutaneous coronary intervention (PCI) to only those patients who meet ACC/AHA appropriateness criteria for the procedure. Hospital and practitioner claims deemed inappropriate are subject to a full payment disallowance.