EFFECTIVE OCTOBER 1, 2011 PHARMACY BENEFITS ARE COVERED BY NEIGHBORHOOD HEALTH PROVIDERS (NHP) and SUFFOLK HEALTH PLAN (SHP) THROUGH EXPRESS SCRIPTS FOR MEDICAID MANAGED CARE and FAMILY HEALTH PLUS MEMBERS

Medicaid and Family Health Plus members will receive a new NHP or SHP ID card with Express Scripts printed on the card. Members will use this new ID card to get their prescriptions and supplies and to access most health care services, except as noted below.* Members should NOT use their Medicaid card on and after October 1, 2011 to get prescriptions. (Members of our Child Health Plus plan will continue to receive their medications via CVS/CareMark).

Express Scripts has an extensive pharmacy network. Members must fill their prescriptions at a network pharmacy. Please note that effective 12/1/11, pharmacies owned and/or operated by Walgreens (Walgreens, Duane Reade, Happy Harry's and OptionCare) will no longer be part of the Express Scripts pharmacy network. Members who have filled prescriptions at any of those pharmacies and who have refills remaining may have their prescriptions transferred to an Express Scripts network pharmacy by calling the new pharmacy and asking them to have their prescription transferred from the Walgreens-affiliated pharmacy. As an alternative, the prescriber can call the new pharmacy with the prescription information.

There are several important policies and procedures to keep in mind:

• Formulary
  NHP/SHP has developed its own formulary, which is somewhat more restrictive than the Medicaid formulary. For a full searchable formulary listing all covered medications and medical supplies, click here. For a list of formulary alternatives to commonly prescribed nonformulary medications, click here.
  
  
• Quantity Limits
  Almost all medications are dispensed as a 30 day supply (except for: 60-90 days for certain estrogen replacement products; 90 days for Boniva IV; contraceptive injections that last for 90 days). Several medications have specific quantity limits. If the medication has a “QLL” indication on the summary or full formulary, these quantity limits apply. Please click here for a list of these medications.
  
  
• Medical Supplies
  NHP/SHP is responsible for the medical supplies that were previously covered under the Medicaid fee-for-service program. A list of covered supplies can be found here. Prescriptions for supplies will be honored at Express Scripts network pharmacies. Supplies, including diabetic test strips, may also be obtained through participating durable medical equipment (DME) vendors. DME items will NOT be dispensed by pharmacies and MUST be ordered through NHP/SHP participating vendors. Some of these require prior authorization.
  
  
• Transition Fill
  If a medication is not on our formulary, members are entitled to up to one medication fill for up to a 30 days supply within 90 days of the transition (until 12/31/11). The member and the prescriber will be sent written notification when that fill takes place, asking them to consider a formulary alternative.
  
  
• Prior Authorization
  Some of your patients' medications may not be covered, or may need a prior authorization. Call Express Scripts at 1-800-287-0358 or fax the Prior Authorization form to 1-800-357-9577.
  
  
• Step Therapy
  Some medications require step therapy.
  
  
• Grandfathered Medications
  Some members will be able to continue receiving the medications they were on before October 1, 2011, even if these medications are not on the NHP/SHP formulary - see the list of “grandfathered” medications.
  
  
• Clinical Drug Review Program
  Members who were on drugs approved by Medicaid’s Clinical Drug Review Program (CDRP) will be able to continue their medications for up to 90 days in most cases.
  
  
• Specialty Drugs
  NHP/SHP will provide "specialty" medications through Express Scripts' specialty mail order pharmacy CuraScript (see the list of covered medications). Members on these "specialty drugs" will be able to get up to two refills at their local pharmacy, but must transition to receiving their medication from CuraScript. Members using other specialty pharmacies must switch to Curascript. Members on specialty drugs and prescribers of these drugs are being contacted by Curascript. There are specific Referral Forms for several conditions and medications - click here for those or use the Prescription Enrollment Form for all other drugs. Selected medications can be filled at an Express Scripts retail pharmacy in urgent situations. Many specialty drugs require Prior Authorization - click here for the list.
  
  
• Synagis® (Palivizumab) for Prophylaxis of RSV Infection
  
• NHP/SHP will follow the NYS Department of Health guidelines for dispensing Synagis® (Palivizumab) for prophylaxis of respiratory syncytial virus (RSV) infection in certain high risk infants and children with a history of prematurity. Synagis® becomes eligible for coverage as of October 15, 2011. Synagis® must be ordered from CuraScript; complete the Synagis Enrollment Form and fax it to CuraScript at 1-866-297-0934. This medication may be given at home if needed, but home care services require prior authorization by NHP/SHP Care Coordination - call 1-800-765-3805.
  
  
• Human Growth Hormone
  
• NHP/SHP requires that documentation be on file for each patient certifying that the Human Growth Hormone (HGH) product is being prescribed for an FDA approved indication before HGH prescriptions can be dispensed. CuraScript Specialty Pharmacy will contact the prescribing physician to obtain specific documentation of a prescriber's certification of an approved FDA indication for the HGH. Click here for a document with FAQs and the Prescriber Certification Form.
  
  
• Co-Payments
  Member co-payments for drugs will not change, except that there will be no copay for medical and diabetic supplies, enteral formulas and hearing aid batteries for Medicaid members after October 1, 2011.
  
  
• Enteral Formulas
  
• Please note that as per NYS Medicaid benefit changes effective April 1, 2011, enteral formulas are restricted to specific subsets of patients (see clinical guidelines). NHP/SHP requires prior authorization for these products. Enteral formula can be provided as a pharmacy benefit (contact Express Scripts for prior authorization at 1-800-287-0358) or through an NHP/SHP-participating DME vendor (call NHP/SHP for prior authorization at 1-800-765-3805).

We will be reviewing our members' recent prescriptions paid for under the Medicaid program and let them know whether they need to contact you for a new prescription. We will also inform you of members who may need to change to a medication on our formulary. We will work with you and your patients to minimize disruption in treatment.

You may request prior authorization or an exception to any of our formulary rules by calling Express Scripts at 1-800-287-0358 on or after October 1, 2011. Your request will be reviewed against NHP/SHP-approved guidelines based on FDA indications and the peer-reviewed medical literature. Members have internal appeal, external appeal and fair hearing rights if a denial is issued.

If you have any questions about pharmacy benefits, please call Provider Services.

• NHP Provider Services 1-800-558-7970
• SHP Provider Services 1-877-747-6789

To contact Express Scripts customer service, please call:

• 1-877-782-8655

* The following drugs will be covered by Medicaid fee-for-service after October 1, 2011:

1. Hemophilia blood factors, whether furnished or administered as part of a clinic or office visit or administered during a home care visit - for Medicaid and Family Health Plus enrollees; and

2. Risperidone microspheres (Risperdal® Consta®), paliperidone palmitate (Invega® Sustenna®), and olanzapine (Zyprexa® Relprevv™) when administered to Medicaid SSI and SSI-related Enrollees.