New Managed Medicaid RX Rule FAQ

 In Advocacy, News, Upcoming events

On July 1, 2019 patients with NY Managed Medicaid Plans will be covered by a new pharmacy rule. The new rule may change where patients with Managed Medicaid can get clotting factor. This F.A.Q. will help explain what’s happening.

What is the new rule?

Starting 7/1/19, Managed Medicaid Plans have the authority to create a pharmacy network and direct patients to only obtain their clotting factor from a plan network pharmacy.

What does this mean if patients have Managed Medicaid?

The new rule means Managed Medicaid plans can tell patients which pharmacies to get clotting factor from.

Will patient pharmacy options be automatically limited?

Each Managed Medicaid plan can choose to limit patients to network pharmacies or not, so it depends on what the different Managed Medicaid plans decide to do.

How will a patient know if their pharmacy options will be limited?

Managed Medicaid plans must send patients a written notice 90 days in advance to notify the patient if there will be a change in which pharmacy the patient can use for factor.

Will all patients be affected at the same time?

No. It depends on when a patient enrolled in Medicaid, and if the Managed Medicaid plan decides to limit patients to only using a network pharmacy.

  • Patients enrolled in Medicaid on or before 7/1/17 had 2 years to use any pharmacy they chose for factor. The 2 years expires on 7/1/19.
  • Patients enrolled after 7/1/17 also have 2 years from the date they enrolled in Medicaid to use any pharmacy they choose for factor.

Managed Medicaid plans can decide at any time after the 2-year option period ends to limit patients to network pharmacies for clotting factor (the plan must send a 90-day written notice first).

Which pharmacies will be in-network?

Each Managed Medicaid Plan can choose any pharmacies they want so long as the pharmacies meet NY Dept. of Health requirements to be in the plan network. Each Plan must have at least 2 designated network pharmacies per county; one must be a pharmacy and one must be an HTC. If there are multiple HTCs serving a county, such as in NYC, NY Dept. of Health requires that when a provider serves five or more enrollees in a Plan, the managed care organization (or MCO) must contract with the HTC (thereby ensuring all HTCs will remain in the plan’s network).

What if a patient wants to use a specific pharmacy?

The patient can search for a Managed Medicaid Plan which has the desired pharmacy in network and switch to that Plan during the enrollment period.

Will this rule affect which clotting factor a patient receives?

No. This rule only affects which pharmacy a patient can use for clotting factor. For questions about coverage of clotting factor and other medication ask your treatment center or local Chapter.

What could this look like to a patient?

John is a bleeding disorders patient with Managed Medicaid coverage. John enrolled in Medicaid on 4/1/17, selected the Healthy You plan from Generic Insurance, and decided to get his clotting factor from Hemo RX pharmacy. On 7/1/19, Generic Insurance decides to create a pharmacy network which only includes 3 pharmacies – RX Choice, RX Option, and RX Source. On July 1, 2019, Generic Insurance sends a letter to John informing him in 90 days John must switch to RX Choice, RX Option, or RX Source for his factor. John must then switch to one of these 3 pharmacies or select another Managed Medicaid plan during the next enrollment period.

What should a patient do if they have problems or further questions?

Two useful website links about Managed Medicaid:

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