NY Manual
SHP Manual

New York Provider Manual
10.2 Laboratory | 10.4 Durable Medical Equipment (DME), Orthotics & Prosthetics

10.3 Pharmacy

Programs and Covered Services

As of 10/1/11, pharmacy services are a covered benefit for Managed Care Healthfirst identification. A comprehensive formulary is available on the Healthfirst website. Pharmacy services are provided by the Healthfirst pharmacy benefit manager (PBM), CVS Caremark, and its network of participating pharmacy providers. If there are any questions, you may call Healthfirst Provider Services at 1-888-801-1660 for Medicaid, CHPlus program,  Commercial, Leaf Plans, and Medicare. A list of participating pharmacies is available from Member Services at 1-866-463-6743 for Medicaid, CHPlus program, and Commercial; 1-888-250-2220 for Healthfirst Leaf Plans; and 1-888-260-1010 for Medicare.

Pharmacy services are a covered benefit in the Medicaid, CHPlus program and Leaf Plans. Medicaid, CHPlus and Leaf Plan members should present their Healthfirst identification cards to pharmacy staff when accessing pharmacy services. A comprehensive formulary is available on the Healthfirst website. Pharmacy services are provided by the Healthfirst pharmacy benefit manager (PBM), CVS Caremark, and its network of participating pharmacy providers. If there are any questions, you may call Healthfirst Provider Services at 1-888-801-1660 for Medicaid, CHPlus program,  Commercial, Leaf Plans, and Medicare. Healthfirst will not cover prescription drugs or biologicals that are used for mercy killings. Please note, members who participate in the Restricted Recipient Program will be restricted to a pharmacy chosen by Healthfirst.

Medicare 65+, IBP, LIP, CC, AC and Commercial: Healthfirst provides coverage for prescription drugs for many of its products. Please refer to the member ID card to determine if a member has pharmacy coverage.

Medicare CBP: Healthfirst does not provide coverage for pharmacy services for CBP members. These members may obtain their prescription coverage from a retiree health plan, the Veterans Administration, or other creditable coverage they may have.

All prescriptions must be filled at a Healthfirst participating pharmacy. Healthfirst may require prior authorization of certain pharmaceuticals. To help your members maximize their pharmacy benefit, consider the following:

Prescription Formulary

Healthfirst plans with drug coverage have a restricted formulary. Providers are encouraged to consider the comparative cost and efficacy of pharmaceutical alternatives when prescribing medication for Healthfirst members. As a part of the Healthfirst prescription drug plan, pharmacists may contact providers to discuss whether an alternative drug might be appropriate for the member. A provider can assist a member in filing a request for an exception to cover a nonformulary prescription. All prescription coverage exception determinations are made by CVS Caremark, Healthfirst’s pharmacy benefits manager (PBM).

All of the formularies for our HF Leaf Plans, Medicare, Medicaid, CompleteCare and CHPlus are available on our website at www.healthfirst.org.

Generic Drugs

Healthfirst strongly encourages the use of generic drugs when clinically appropriate. The member’s copayment will be less if a generic equivalent is prescribed. Please note the following maximum days’ supply:

·     Commercial [Healthy NY Small Group; Healthfirst HMO B Small Group] – 30 days
·     HF Leaf Plans – 90 days Leaf Plans – 90 days  
·     Medicaid  and CHPlus – 30 days
·     CHPlus – 30 days
·     Medicare – 90 days
·     Mail order for Commercial, HF Leaf Plans, and Medicare – 90 days
·     Over-the-Counter (OTC) Benefits (Medicare)

Eligible Medicare plan members can obtain OTC or nonprescription drugs and health-related items without a prescription at any OTC network pharmacy location. Eligible members will receive a Healthfirst OTC Card with a prefunded monthly benefit allowance upon enrollment. With this allowance, the member may purchase eligible OTC and health-related items (i.e., aspirin, cold & flu relief medications, and adhesive bandages) at any participating OTC network pharmacy, including any Rite Aid, Duane Reade, Walgreens, CVS, or Family Dollar location. In addition, the Healthfirst OTC card can be used at many neighborhood pharmacies. 

To purchase items, members will take their eligible items to the front checkout lanes of a participating store and swipe the card at any register. Purchases for eligible items are automatically deducted from the OTC card balance. Any remaining balance will carry over until the next purchase.. Any unused balances automatically expire at the end of the calendar year on December 31st or upon disenrollment from the plan.

If a member makes purchases of eligible OTC items at a store without the product-linked OTC card technology or from a store where the product-linked OTC card technology failed or was unavailable, he/she may submit an Over-The-Counter (OTC) Reimbursement Claim Form. This form is available at www.healthfirst.org or by calling Member Services.

For a complete list of covered OTC items, please visit www.healthfirst.org.

Specialty Medications

Healthfirst uses a pharmacy vendor to help manage the care members receive and who need oral and injectable specialty medications. The vendor verifies eligibility, submits requests for prior authorization, and bills the member-appropriate copayments or coinsurance for medications. Providers must order specialty medications directly through the delegated vendor. Providers will not be reimbursed for specialty medication claims submitted to Healthfirst.

The following items are not covered, or are covered as noted:

·     Needles or syringes (except for diabetes) 
·     Appetite suppressants
·     Erectile dysfunction medication 
·     Growth hormones are covered under a member’s medical benefit when medically necessary
·     Prescription vitamins
·     Cosmetic drugs, Rogaine (Minoxidil)
·     Anabolic steroids
·     Fertility agents