From: OMH Bureau of Health Services

Date: September 30, 2011

Re: Pharmacy Benefit Updates

We're sending you this memorandum to alert you to a number of changes that may have a significant impact on medication prescribing in your practice. The consumers you serve may be receiving complex information by mail regarding their medication and these changes. The changes may necessitate that you work directly with the consumer and their plan to continue to give the consumer the support they need.

Some consumers are already enrolled in a Primary Care Plan managed care alternative to Fee for Service Medicaid (FFS). Over time, most consumers who are currently enrolled in traditional FFS will be transitioned to a (MMC) plan. Depending on enrollment status, the pharmacy benefit may vary.

1. For the Seriously and Persistently Mentally Ill (SPMI) consumer enrolled in a MMC plan, their pharmacy benefit will be provided by the MMC plan.
2. For the dual eligible consumer, (Medicare and Medicaid) their pharmacy benefit will be provided by the Medicare Part D plan with only limited supplements from Medicaid for Medicare Part D excluded classes (over the counter medications, barbiturates, and benzodiazepines for example). Antipsychotics and antidepressants not covered on the Part D plan will need prior authorization from the Part D plan to continue coverage.
3. For those receiving SSI (Supplemental Security Income), the majority of their medications will be provided by their MMC plan but long acting atypical anti-psychotics will be covered as a "physician service billing" rather than a pharmacy benefit by Medicaid.

Clinics and prescribers may want to think about how best to communicate these changes to the consumers they serve.

For stabilized patients, you should work with consumers and their plans to ensure continuity of treatment. Careful titration and monitoring should be used if medication changes are warranted. Most of the Medicaid Managed Care plans have agreed to continue the same mental health medications for patients that are stabilized regardless of the published formulary.

We have included supplemental information as tools to assist you in this process. Among the attachments are a summary of the changes, cross-walks of the antipsychotic and antidepressant classes for both the Medicaid Managed Care and Medicare Part D plans, a listing of Medicaid Managed Care plans with links to their formulary websites, the Medicaid Preferred Drug List, and a phone contact list for the Medicaid Managed Care Plans.

For Consumers:
NYS Consumer Medicaid Helpline 800-541-2831
Enrollment letters, NY Health Options 866-976-3526