2011 Medicaid Benefit Changes

In 2011, New York State Governor Andrew Cuomo created a Medicaid Redesign Team to make changes to Medicaid, which included changing some of the benefits. As a result, all New York Medicaid Managed Care health plans, including SHP, modified their Medicaid benefits to comply with the changes. Below is current information on the SHP 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, your pharmacy benefits are provided through SHP, your Medicaid health plan. (Your pharmacy benefits used to be provided through the Medicaid fee-for-service program using your Medicaid Benefit card).

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. Medicaid Benefit cards cannot be used for prescriptions.
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 Medicaid members, co-payments per drug are:

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

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.

Personal Care / Home Attendant Service
Personal Care / Home Attendant Service must be medically necessary and arranged by SHP. This service provides some or total assistance with personal hygiene, dressing, feeding, meal preparation, and housekeeping. SHP will review all requests for home care services, including increases in the current level of services and renewals of service authorizations.

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.

Prescription Footwear and Compression Stockings
There are limits on prescription footwear and compression stockings.

Prescription footwear is not covered except:

For members under 21 years of age, who require orthopedic footwear to correct, accommodate or prevent a physical deformity or range of motion malfunction in a diseased or injured part of the ankle or foot.
For members under 21 years of age, who require footwear to support a weak or deformed structure of the ankle or foot.
When a shoe is attached to a lower limb orthotic brace. Doctors will need to get prior authorization from SHP for members who are age 21 and older.
As part of a diabetic treatment plan to treat amputation, or pre-ulcerative calluses, or peripheral neuropathy with evidence of callus formation of either foot, or a foot deformity or poor circulation.

Compression stockings are not covered except in the following circumstances:

Below-the-knee compression stockings (30-40mm Hg or 40-50mm Hg) are covered only when used for treatment of an open venous statis ulcer.
Full-length surgical stockings are covered only when used for treatment of severe varicosities and edema during pregnancy.

Smoking Cessation Counseling
Smoking cessation counseling services are covered for all Medicaid 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.