NY Manual
SHP Manual

New York Provider Manual
15.7 Coverage Determinations for Part D Prescription Drugs – Medicare | 15.9 Action Denial Notice – Medicaid, FHPlus and CHPlus

15.8 Coverage Determinations for Prescription Drugs – Medicaid, CHPlus and Leaf Plans

The formulary outlining the Medicaid, Child Health Plus, and Leaf Plans pharmacy benefits can be found on the Healthfirst website www.healthfirst.org/formulary.html.

Coverage determinations include requests for prior authorization or formulary exceptions.

Healthfirst strongly encourages/recommends that a prescribing provider review the current Medicaid, CHPlus, and Leaf Plan formularies to identify the drugs that are covered for Healthfirst members. The formulary can help a provider identify the therapy or therapies that will be least expensive for the member. In general, the lower the drug tier, the lower the cost of the drug. In addition, the formulary can help a provider identify the drugs and therapies that are preferred by Healthfirst. The formulary was developed by a Pharmaceutical and Therapeutics Committee (P&T) comprising a national panel of clinicians. The formulary can help providers understand the Healthfirst strategy for managing the pharmacy benefit. Healthfirst recognizes that sometimes this strategy may not align with a provider’s treatment criteria.

Some covered drugs may have additional requirements or limits on coverage. These requirements or limits may include:

·     Prior Authorization: Healthfirst requires prior authorization for certain drugs. This means that approval from Healthfirst must be obtained before the prescription is filled. If approval is not obtained, Healthfirst may not cover the drug 
       In order to obtain prior authorization, prescribers should contact CVS Caremark at 1-877-433-7643 and be prepared to provide relevant clinical information that supports the medical necessity of the required medication. A comprehensive formulary is also available on the Healthfirst website www.healthfirst.org or by contacting the Member Services department at 1-866-463-6743. 
·     Quantity Limits: For certain drugs, Healthfirst limits the amount of the drug that is covered.
·     Step Therapy: In some cases, Healthfirst requires a member to first try certain drugs to treat their medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat the medical condition, Healthfirst may not cover Drug B unless the member tries Drug A first. If Drug A does not work for the member, Healthfirst will then cover Drug B. However, if it is a new member who has already tried Drug A before taking Drug B, Healthfirst will not require the member to try Drug A again. You should notify us if this is the case.

You can ask Healthfirst to make an exception to these restrictions or limits. Please contact CVS Caremark at 1-877-433-7643 for information about how to request an exception.

To initiate a coverage determination request, including a request for a drug that is not on the formulary (formulary exception), please contact the CVS Caremark Prior Authorization department in any of the following ways:

Coverage determinations for Medicaid and CHPlus

·     CALL CVS Caremark at 1-877-433-7643
Calls to this number are free, 8:00am–6:00pm CST
·     FAX 1-866-848-5088

While no specific form is required, the NY State Medicaid Standard Global Prior Authorization form can be found at the website:  www.healthfirst.org/providerforms.

WRITE::   CVS Caremark

                                    Attn: Healthfirst NY Medicaid Prior Authorization

                                    1300 E. Campbell Road

                                    Richardson, TX 75081

Healthfirst’s Medicaid and CHPlus formulary, as well as Prior Authorization (PA), Step Therapy (ST), and Quantity Limit (QLL) criteria listings, can be found on Healthfirst’s public website: www.healthfirst.org/formulary.html.​

Coverage determinations for Leaf Plans

·     CALL CVS Caremark at 1-800-294-5979
·     FAX 1-888-836-0730
          Calls to these numbers are free, 8:00am–6:00pm CST.
·     WRITE 
CVS Caremark
Attn: Healthfirst NY Exchange Prior Authorization
1300 E. Campbell Road
Richardson, TX 75081 

Healthfirst’s Exchange formulary, as well as Prior Authorization (PA), Step Therapy (ST) and Quantity Limit (QLL) criteria listings, can be found on Healthfirst’s public website www.healthfirst.org/formulary.html.​