Under this program, EmblemHealth promotes the use of less expensive, equally effective prescription drugs when medically appropriate. EmblemHealth Medicaid members must use pharmacies that will accept their benefit ID card; pharmacies must comply with all applicable Medicaid program requirements.
We cover the following pharmacy services for members with EmblemHealth Medicaid coverage:
- As of October 1, 2011, EmblemHealth covers pharmacy benefit services for all EmblemHealth Medicaid members. The benefit includes prescription drugs, all Medicaid covered over-the-counter medications, diabetic supplies, select durable medical equipment and medical supplies.
- EmblemHealth covers medical/surgical supplies routinely furnished or administered as part of an office visit for EmblemHealth Medicaid members. Note: Medical/surgical supplies dispensed in a doctor's office or other non-inpatient setting, or by a certified home health aide as part of an at-home visit, are not covered as separate billable items.
For more details on coverage of medical/surgical supplies, please refer to Appendix B in the Provider Networks and Member Benefit Plans chapter.
NYSDOH Medicaid Prior Authorization Request Form for Prescriptions
The New York State Department of Health (NYSDOH) has created a New York State Medicaid Prior Authorization Request Form for Prescriptions to streamline managed care organizations' prior approval procedures for medications prescribed to members covered by Medicaid. EmblemHealth is complying with NYSDOH's requirement to use this form.
If the drug you want to prescribe to your EmblemHealth Medicaid patient requires prior approval, please download and complete the New York State Medicaid Prior Authorization Request Form for Prescriptions and fax it to 1-877-300-9695.
The member may also download this form and present it to you for completion. Please fill out the form and fax it to the number above.
Prior approval is required for:
- Non-preferred medications (except for typical anti-psychotics, anti-depressants, anti-rejection drugs and anti-retroviral drugs used for HIV/AIDS)
- Drugs with coverage limitations (e.g., frequency, quantity, duration limits)
- Drugs that require clinical review (e.g., step protocols, certificate of medical necessity)
- Generics when the cost of the brand name is less than the generic
Prior approvals may be obtained by calling 1-866-447-9717. Prior approvals are valid for up to six months, with a maximum of five refills.
The EmblemHealth Medicaid Formulary excludes medications used for:
- Weight loss
- Erectile dysfunction
- Promotion of fertility
- Cosmetic purposes
It also excludes drugs without a National Drug Code (NDC). In addition, under the Mandatory Generic Program, coverage for brand name medications is excluded when the FDA has approved an A-rated generic equivalent, unless a prior approval is obtained or the drug is exempted.
For more information on the EmblemHealth Medicaid Formulary click here.
Vaccines for Children Program
EmblemHealth requires all eligible Child Health Plus (CHPlus) and Medicaid providers to participate in the Vaccines for Children (VFC) Program. The VFC Program is a New York State Department of Health (NYSDOH) and New York City Department of Health and Mental Hygiene (NYCDOHMH) program that distributes free vaccines to eligible providers that serve CHPlus/Medicaid members under 19 years of age within New York City (Bronx, Kings, New York, Queens, Richmond counties) and Nassau, Suffolk and Westchester counties. Members that meet these criteria are commonly referred to as VFC-eligible members.
Although vaccinations are a covered benefit for CHPlus/Medicaid members, EmblemHealth is not responsible for the cost of the vaccines available through the VFC Program.
EmblemHealth will only reimburse Providers for the cost of administering vaccines to VFC-eligible members. Providers are required to bill vaccine administration code 90460 for administration of vaccines supplied by VFC, including influenza and pneumococcal administration. For reimbursement purposes, the administration of the components of a combination vaccine continues to be considered as one vaccine administration. More than one vaccine administration is reimbursable under vaccine administration code 90460 on a single date of service.
The following is a list of the CPT codes for vaccines that will be auto-denied when administered to any VFC-eligible members under the age of 19 years: 90633, 90636, 90647, 90648, 90649, 90650, 90670, 90672, 90680, 90681, 90685, 90686, 90696, 90698, 90700, 90707, 90710, 90713, 90715, 90716, 90718, 90723, 90732, 90734, 90744, 90748.
Regulations Regarding Known Sex Offenders in Government Programs
As per government legislation, we do not cover supplies for the treatment of erectile dysfunction (ED) for sex offenders enrolled in any state-sponsored programs.
For more information regarding the prior approval program created by the New York State Department of Health for Medicaid members for the provision of ED procedures and supplies, see Prior Approval for Procedures, Supplies and Drugs for Erectile Dysfunction Treatment in the Care Management chapter.
Glossary terms found on this page:
Services that have been approved for payment based on a review of EmblemHealth's policies.
A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.
Occurs when a clinical professional reviews information about a patient's health.
The date on which a service was rendered.
Medical equipment, goods, implements and prosthetics that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs and walkers.
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 that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.
A card which allows the subscriber to identify himself or his covered dependents to a provider for health care services.
Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.
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.
Specific circumstances or services listed in the contract for which benefits will be limited.
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.
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.
A public agency that works to control the spread of infectious diseases, monitor the health of New Yorkers and create an environment that protects and promotes health by using regulations, education and advocacy and providing direct health services. Also known as NYCDOHMH.
The state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called NYSDOH.
A public agency that works to control the spread of infectious diseases, monitor the health of New Yorkers and create an environment that protects and promotes health by using regulations, education and advocacy and providing direct health services. Also known as the New York City Department of Health and Mental Hygiene.
The state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called the New York State Department of Health.
A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.
A written order or refill notice issued by a licensed medical professional for drugs available only through a pharmacy.
Drugs and medications that are required by law to be dispensed by written prescriptions from a licensed physician.
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
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- 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.
A set of providers contracted with a health plan to provide services to the enrollees.
New York State Department of Health. This agency provides information for consumers, doctors, researchers and health care providers.