Prescription Drugs

presdrugs

Medicaid

For medications not listed on the Formulary, providers may follow the same course of action as with a Coverage Determination, also called a Prior Authorization. This can be initiated by having your Provider fax a Prior Authorization Request to (844) 823-5479 for the medication(s) whether or not it is listed on the Formulary. Should this coverage be denied, an appeal can be made within 60 days of the initial denial by calling (800) 223-7242.

2021 Covered Drug List (Formulary)
2022 Covered Drug List (Formulary) (Coming Soon)

Single Statewide Medication Assisted Treatment (MAT) Formulary

STARTING OCTOBER 1, 2021.The New York State Executive Budget for State Fiscal Year 2020-2021, in accordance to § 367-a (7) (e) of Social Services Law, enacts a statewide formulary for Opioid Antagonists and Opioid Dependence Agents for Medicaid Managed Care (MC) Plans and Medicaid Fee for Service (FFS) Program,  Under this statewide formulary (link provided below), Medicaid MC and FFS members will follow a single formulary, where preferred products and coverage parameters are consistent across the Medicaid Program.

For more information, please visit https://newyork.fhsc.com/providers/mat.asp.

 

A Convenient Way to Fill Prescriptions

At your local pharmacy
You can use your prescription benefit ID card at most chain and independent pharmacies across the country. Find a participating pharmacy near you using the Pharmacy Locator.

 

Specialty Medications

These are high-cost, injectable, oral, infused or inhaled medications that are typically self-administered.

Specialty Guideline Management (SGM)
SGM is our utilization management program; administered by CVS Caremark, that helps ensure appropriate utilization for specialty medication based on currently accepted evidence-based medicine guidelines. SGM is designed to ensure safety and efficacy while preventing off-guideline utilization. Prescribers may call (800) 237-2767 to enroll patients in the Specialty plan design.

Comprehensive Contraception Coverage Act (CCCA)

You are covered for all forms of contraceptive drugs, devices and products approved by the U.S. Food and Drug Administration (FDA). This includes all FDA-approved over-the-counter contraceptive products as prescribed or as otherwise authorized under state or federal law. You are also permitted to receive an entire 12-month supply of a contraceptive at once.

Where the FDA has approved one or more therapeutic and pharmaceutical equivalent versions of a contraceptive drug, device or product, Affinity Health Plan is not required to include all of the therapeutic and pharmaceutical equivalent versions in its formulary, so long as at least one is included and covered without cost-sharing.

Your contraceptive coverage is provided without any cost-sharing, including any deductible, coinsurance or copayment. Prior authorization, step therapy protocols, or quantity limits on a 12-month supply are not permitted for your contraceptive coverage.