Medicaid Pharmacy Program

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.

Effective January 1, 2017, our Medicaid/HARP members will no longer be able to fill prescriptions at CVS or Target. When writing prescriptions for these members, especially when ePrescribing or prescribing controlled substances, please ask them to designate a new pharmacy. Although members can arrange to have certain prescriptions moved from CVS or Target to a new pharmacy, if you are able to have the prescription sent to the right place, it will improve the member’s experience and increase the likelihood of medication compliance.

Use the Medicaid Pharmacy Locator to find alternate pharmacies to recommend to your Medicaid members.

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

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.

Excluded Medications

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.