Medicaid and Family Health Plus Pharmacy Services

New Pharmacy Tools

Pharmacy Benefit Brochure
(Spanish version)

* Effective 10/1/2011

We cover pharmacy benefit services for all our Medicaid managed care and Family Health Plus members. You must use our network pharmacies to fill all of your prescriptions and any covered over-the-counter medications, diabetic supplies, select durable medical equipment and medical supplies.

Pharmacy Benefits

Medicaid Managed Care Pharmacy Benefit includes:

Prescription drugs
Over-the-counter medicines (OTC)
Insulin and diabetic supplies
Smoking cessation agents, including OTC products
Hearing aid batteries
Enteral formula
Emergency contraception (6 per calendar year)
Medical and surgical supplies

Medicaid Managed Care Copayments

Prescription Item	Copayment Amount
Non preferred brand-name Prescription drugs	$3.00/$1.00
Generic prescription drugs	$1.00
Over-the counter medications (e.g., for smoking cessation and diabetes)	$0.50 per medication

Note: One copay charge for each new prescription and each refill

Services to Which Copayments DO NOT Apply

Emergency room visits for needed emergency care.
Family planning services, drugs, and supplies like birth control pills and condoms.
Mental health clinic visits.
Chemical dependency clinic visits.
Drugs to treat mental illness (psychotropic).
Drugs to treat tuberculosis.
Prescription drugs for residents of Adult Care Facilities.

Note: One copay charge for each new prescription and each refill

Members to Which Copayments DO NOT Apply

Members under age 21.
Pregnant women (though 60 days postpartum).
Residents of community-based residential facilities licensed by the Office of Mental Health or the Office of People with Developmental Disability.
Members in a Comprehensive Medicaid Case Management (CMCM) or Service Coordination program.
Members in an OMH or OPWDD Home and Community Based Services (HCBS) Waiver program.
Members in a DOH HCBS Waiver program for Persons with Traumatic Brain Injury (TBI).
Members who are financially unable to make copayments at any time who tell the provider that they are unable to pay.

You will not be denied health care services based on your inability to pay the copayment at the time of service. However, you will still owe the unpaid co-pay to the provider, and the provider may bill you or take other action to collect the owed amount.

If you are required to pay a copay you are responsible for a maximum of $200 per calendar year. If you transfer from one health plan to another during the calendar year, keep your receipts as proof of your copayments or you may request proof of paid copayments from your pharmacy. You will need to give a copy to your new plan.

Family Health Plus (FHPlus) pharmacy benefit includes:

Prescription drugs
Select over the counter (OTC) medicines such as Prilosec OTC, Loratadine, Zyrtec
Smoking cessation products, including over-the-counter (OTC) products
Hearing aid batteries
Vitamins necessary to treat an illness or condition
Insulin and diabetic supplies
Enteral formula
Emergency Contraception (6 per calendar year)

Note: Medical supplies, other than diabetic supplies and smoking cessation products, are not covered.

Services to Which Copayments DO NOT Apply

Emergency room visits for needed emergency care.
Family planning services, drugs, and supplies.
Mental health clinic visits.
Chemical dependency clinic visits.
Drugs to treat mental illness (psychotropic).
Prescription drugs for residents of Adult Care Facilities.

You will not be denied health care services based on your inability to pay the copayment at the time of service. However, you will still owe the unpaid copay to the provider, and the provider may bill you or take other action to collect the owed amount.

Members who do not have to make Copayments

Children under age 21.
Pregnant women (through 60 days postpartum).
Members who are financially unable to make copayments at any time and who tell the provider that they are unable to pay.
A resident in a community based residential facility licensed by the Office of Mental Health or the Office of People with Developmental Disability.

FHPlus Copayments

Prescription Item	Copayment Amount
Brand-name Prescription drugs	$6.00
Generic prescription drugs	$3.00
Over-the counter medications (e.g., for smoking cessation and diabetes)	$0.50 per medication

Note: One copay charge for each new prescription and each refill

Services to Which Copayments DO NOT Apply

Emergency room visits for needed emergency care.
Family planning services, drugs, and supplies like birth control pills and condoms.
Mental health clinic visits.
Chemical dependency clinic visits.
Drugs to treat mental illness (psychotropic) and tuberculosis.
Drugs to treat tuberculosis.
Prescription drugs for residents of Adult Care Facilities.

Members who do not have to make Copayments

Members under age 21.
Pregnant women (though 60 days postpartum).
Members who are financially unable to make copayments at any time who tell the provider that they are unable to pay.

FHPlus Copayments

Prescription Item	Copayment Amount
Brand-name Prescription drugs	$6.00
Generic prescription drugs	$3.00
Over-the counter medications (e.g., for smoking cessation and diabetes)	$0.50 per medication

Note: One copay charge for each new prescription and each refill

Home Delivery of a New Prescription

You may get home delivery of your maintenance drugs through our mail order pharmacy partner Express Scripts, Inc. (ESI). Maintenance drugs are used to treat chronic conditions and are usually prescribed in quantities greater than 30-day supplies. All you need to do is get a new written prescription from your doctor or other licensed health care provider, and mail it to ESI along with the completed order form. You may request an ESI order form to be mailed to you by calling our Pharmacy Customer Service at 1-888-447-7364. Mail the form and the original prescription(s) along with the required copayment to ESI as directed on the form. You may include multiple new prescriptions in your order.

If you prefer, your doctor or other licensed health care professional can assist you. You can bring your order form to them and they can fax it to ESI directly with your prescription. Or they can submit your prescription via the Web. In both cases, they must have your member ID number. Only doctors or other licensed health care providers may submit new prescriptions via fax or Web.

To use the Home Delivery tool, go to myEmblemHealth and register if you haven't already. Click on “Pharmacy Services” and then select “Home Delivery”. You will be able to do things like check order status and request refills to existing prescriptions. You will need to register the first time you use the tool, and you will need your member ID to create an account. You or your doctor will still need to send ESI the actual written prescription when using the online option. Please allow 7 to 10 days for delivery from the day ESI receives the prescription(s) to receive your home delivery.

Check on the status of a home delivery prescription order
You can easily check the status of your order via the EmblemHealth/Express Scripts pharmacy benefits tool on this page. You will need to sign in using your member ID and password. You can also call ESI at 1-877-866-4165. If you have a hearing or speech impairment, and use a TDD, you can call 1-800-899-2114. You will need your member ID number and your prescription number(s) to access this information.

Specialty Drugs

Specialty drugs are usually injectable, oral or inhaled drugs. They are used to treat chronic conditions such as multiple sclerosis, growth deficiencies, hepatitis C and cancer. They also require special storage and/or handling. You must have your specialty drug prescriptions filled through our select Specialty Pharmacy program. You cannot fill specialty drug prescriptions at a network retail pharmacy or through the ESI mail order program. Your doctor or other licensed health care provider will submit the prescription through our Specialty Pharmacy program. And similar to home delivery, your specialty prescriptions will be filled and sent directly to you at home.

For questions, please call EmblemHealth's Specialty Pharmacy program at 1-888-447-0295.

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