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  • Pharmacy Services > Medicaid Pharmacy Behavioral Health Carve-in

    EmblemHealth expanded the Behavioral Health Benefit offered to Medicaid members. The Behavioral Health Pharmacy services previously covered under Fee-for-Service Medicaid through SSI will now be covered through EmblemHealth.

    Emergency Pharmacy for Members with a Behavioral Health Condition

    Except where otherwise prohibited by law:

    1. EmblemHealth allows immediate access without prior authorizations to a seventy-two (72) hour emergency supply of the prescribed drug or medication for an individual with a behavioral condition experiencing an emergency condition as defined in the Medicaid Managed Care Model Contract.
    2. EmblemHealth will immediately authorize a seven day supply of a prescribed drug or medication associated with the management of opioid withdrawal and/or stabilization.

    Injectable Anti-Psychotic Agent Access

    Medicaid members are entitled to obtain injectable anti-psychotic agents through their medical or pharmacy benefit. 

    Medical Benefit Process

    • Buy and Bill - A prescriber can purchase, and bill for, an inventory of injectable anti-psychotic agents directly from the manufacturer or willing licensed pharmacy and store them in the office for administration to patients.
    • Voluntary Specialty Pharmacy Program - A prescriber can request injectable anti-psychotic agents through Specialty Pharmacy Services. After the prescriber satisfies the prior approval (PA) criteria, Specialty Pharmacy Services will issue a prior approval, and our contracted medical provider will ship the anti-psychotic agent to the prescriber’s office for administration to the patient at no additional cost to the prescriber.

    Pharmacy Benefit Prior Approval Process

    Medicaid members may obtain first-generation injectable anti-psychotic agents from any network retail pharmacy that participates in our Specialty Pharmacy Network without prior approval. Medicaid members will require prior approval for second-generation injectable anti-psychotic agents. Medicare members require prior approval for both first and second generation injectable anti-psychotic agents.

    Smoking Cessation Products

    Medicaid members with a diagnosis of mental illness or substance use disorder are entitled to obtain unlimited courses of smoking cessation therapy and are permitted the concomitant utilization of two smoking cessation products.

    The EmblemHealth Medicaid Formulary currently includes all categories of smoking cessation products. Medicaid members have access to these products without prior approval criteria or quantity limits.

    For more information on the EmblemHealth Medicaid Formulary, visit https://member.express-scripts.com/web/formulary/OpenFormulary.do?hidePDFs=true&formularyId=3547&clientId=emblem.

    Drugs Used for the Treatment of Substance Use Disorder

    Medicaid members are entitled to obtain naloxone vials, naloxone prefilled syringes, and extended-release naltrexone through the medical or pharmacy benefit. In addition, at least one formulation of buprenorphine and buprenorphine/naloxone shall be included on the Medicaid Formulary.

    Medical Benefit Process

    • Buy and Bill - A prescriber can purchase, and bill for, an inventory of naloxone vials, naloxone prefilled syringes, and extended-release naltrexone directly from the manufacturer or willing licensed pharmacy and store them in the office for administration to patients.
    • Voluntary Specialty Pharmacy Program - A prescriber can request extended-release naltrexone through Specialty Pharmacy Services. After the prescriber satisfies the prior approval (PA) criteria, Specialty Pharmacy Services will issue a prior approval, and our contracted medical provider will ship the opioid antagonist to the prescriber’s office for administration to the patient at no additional cost to the prescriber.

    Pharmacy Benefit and Prior Approval Process

    Medicaid members may obtain naloxone vials, and naloxone prefilled syringes from any network retail pharmacy without prior approval. Extended-release naltrexone requires prior approval and may be obtained from any pharmacy that participates in our Specialty Pharmacy Network.

    Effective March 8, 2016, Prior approval will no longer be required for generic buprenorphine/naloxone. Branded buprenorphine/naloxone products will still require prior approval. Both may be obtained from any network retail pharmacy.

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    Glossary terms found on this page:

    Services that have been approved for payment based on a review of EmblemHealth's policies.

    Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

    A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

    Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

    Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

    A payment method in which the insurer will reimburse the member or provider directly for each covered medical expense.

    A list of preferred pharmaceutical products that health plans, working with pharmacists and physicians, have developed to encourage greater efficiency in the dispensing of prescription drugs without sacrificing quality. Also called a drug formulary.

    An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    A permit (or equivalent) to practice medicine or a health profession that is: 1) issued by any state or jurisdiction in the United States and 2) required for the performance of job functions.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires prior approval of certain services.

    A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

    An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

    The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

    The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

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