2011 Family Health Plus(FHP)
Benefit Changes

In 2011, New York State Governor Andrew Cuomo created a Medicaid Redesign Team to make changes to the Medicaid and Family Health Plus programs, which included changing some of the benefits.  As a result, all New York Medicaid Managed Care health plans, including SHP, modified their Medicaid and Family Health Plus benefits to comply with the changes.

Below is current information on the Family Health Plus benefits that were affected.  For additional information on any of these benefits, please contact our Member Services department at 1-877-747-6789.

Pharmacy
As of October 1, 2011, SHP has partnered with Express Scripts to provide your pharmacy benefits. You can view a list of drugs that are covered (also called a formulary) by clicking here. If you have been prescribed a drug that is not covered, then you or your pharmacist may need to talk to your doctor about changing to a drug that is on the formulary. 

In order to fill a prescription, members must:

  • Use their SHP ID card. New SHP ID cards were mailed in September 2011.
  • Visit a pharmacy in the Express Scripts network.  To find a pharmacy in the network, please call Express Scripts at 1-877-782-8655 or click here.

  • Please click here for important information about Walgreens pharmacies.

Some covered drugs require a co-payment.  For FHP members, co-payments per drug are:

  • $6 for some brand-name drugs
  • $3 for generic drugs and some brand-name drugs (those that are on the FHP preferred drug list)
  • $50 cents for over-the-counter drugs
  • $1 for covered supplies

  • There is no co-payment for family planning drugs and supplies like birth control and condoms. There is no-copayment for drugs to treat mental illness or tuberculosis.

Some members do not require co-payments:

  • Members younger than 21 years old
  • Members who are pregnant
  • Members in certain service coordination or waiver programs

Certain drugs may require that your doctor get prior authorization from us before writing your prescription.  Your doctor can work with SHP to make sure you get the medicine you need.

Physical Therapy, Occupational Therapy and Speech Therapy
Up to 20 physical, occupational or speech therapy visits are covered each year if they are provided in private doctors’ offices, hospital outpatient departments, or diagnostic/treatment centers. This limit does not apply to members under age 21, members with developmental disabilities or traumatic brain injury.  This limit also does not apply to services provided in a nursing home, inpatient hospital or as part of a home care program.

Enteral Formula
Enteral formula is covered only under one or more of the following circumstances:

  • For members who cannot chew or swallow food and have to obtain nutrition through a tube.
  • For members who were born with rare metabolic disorders who need specific medical formulas to provide nutrition that is not available through any other means.
  • For members who are children under age 21 and require formula due to certain problems with growth and development.

Smoking Cessation Counseling

Smoking cessation counseling services are covered for all FHP members over age 9 who smoke.  Pregnant members will continue to be eligible for up to six (6) counseling sessions during their pregnancy and up to six (6) sessions during the six-month period after they have given birth. All other members may receive up to six (6) sessions per calendar year.