What medications are covered?
Want to know in advance what medications MetroPlusHealth will help pay for? Look it up in your plan formulary. A formulary is a list of prescription drugs and therapies that an insurer has approved for its members.
We will generally cover anything listed in our formulary as long as the drug is medically necessary, the prescription is filled at a MetroPlusHealth network pharmacy, and other plan rules are followed. Your plan benefits page can explain in more detail. Of course, if you still have questions, you can always call or contact us.
| Formularies | Documents (PDF) |
|---|
Medicaid
Child Health Plus
Partnership In Care (SNP)
MetroPlusHealth Enhanced (HARP) | effective date: February 2023 As a requirement by the NY Department of Health, MetroPlus Health Plan, in alignment with NYS Medicaid Fee-For-Service, provides coverage for select over the counter (OTC) medications or products when a prescription is presented at a NYS enrolled participating network pharmacy. Select analgesics, allergy, cough and cold preparations, digestive products, insulin, topical products, and vitamins with or without minerals may be eligible for coverage. Not all formulations, sizes or products are covered in every category. If the product National Drug Code (NDC) is not found on the NYS Medicaid FFS formulary file, then it is not eligible for coverage. The link to the Medicaid FFS list of reimbursable drugs is available here: https://www.emedny.org/info/formfile.aspx. |
| Medicaid, SNP, HARP Non-enrolled Provider Override Guidance | effective date: October 2022 |
Marketplace Plans (Individual)
Essential Plan | effective date: March 2023 |
| MetroPlus Gold | effective date: March 2023 |
| MetroPlus GoldCare I & II | effective date: March 2023 |
Medicare
UltraCare | effective date: February 2023 |
The links open documents in PDF, Word or Excel format. If you have problems viewing any of the documents contact your Provider Services Representative. Download Acrobat Reader, a PDF viewer.
MEDICATION ASSISTED TREATMENT (MAT) FORMULARY CHANGE NOTIFICATION FOR METROPLUSHEALTH MEDICAID MANAGED CARE, PARTNERSHIP IN CARE (PIC) HIV-SNP, AND ENHANCED (HARP) PLAN MEMBERS
Effective March 22, 2022, prior authorization will not be required for medications used for the treatment of substance use disorder prescribed according to generally accepted national professional guidelines for the treatment of a substance use disorder. Prescriptions written outside of accepted guidelines may be subject to prior authorization. For more information and a list of medications, please visit here.
Prescriptions for a brand name multi-source drug will be filled with a generic equivalent, as required by New York State Social Services and Education Law, unless the Prescriber indicates “Dispense as Written (DAW)”, and “Brand Medically Necessary” on the prescription.
Provider Tools
- To view our Pharmacy Policies (for Providers, including Pharmacies), click here.
