At MetroPlusHealth, we want to make things easier for our providers. We are working to improve how you can check member medication coverage, while making the outpatient drug exception process smoother and more efficient.
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Pharmacy Benefit
Medication Obtained Through a Dispensing Pharmacy
MetroPlusHealth’s pharmacy benefit is administered by CVS Caremark.
Drug Coverage
To find information about covered medications, formulary requirements, and pharmacy benefit coverage, please click here:
Prior Authorizations & Appeals
Pharmacy Benefit Prior Authorization Process
Medicaid, Partnership In Care (SNP) & Enhanced (HARP) Members
Prior authorizations for all medications are reviewed through NYRx.
Resource: NYRx Prior Authorization Information
For additional pharmacy benefit questions, please reach out to the NYRx Pharmacy Support line at
1-518-486-3209.
Medicare & UltraCare Members
Child Health Plus, Essential Plan, Gold & Marketplace Members
Specialty Drugs
Reviewed by CVS Specialty.
- Online: Caremark ePA
- Phone: 1-866-814-5506
Non-Specialty Drugs
Reviewed by CVS Caremark.
Prior Authorization & Appeals Contacts
| Plan | Customer Care | PA Phone | PA Fax | Appeals Fax |
|---|---|---|---|---|
| Child Health Plus | 1-855-656-0361 | 1-800-294-5979 | 1-866-255-7569 | 1-844-802-1405 |
| Gold / Gold Care | 1-855-656-0361 | 1-800-294-5979 | 1-888-836-0730 | 1-866-433-1172 |
| Essential Plan | 1-855-383-9426 | 1-800-294-5979 | 1-888-836-0730 | 1-866-433-1172 |
| Marketplace & QHP | 1-855-383-9426 | 1-800-294-5979 | 1-888-836-0730 | 1-866-433-1172 |
Medical Benefit
Physician-Administered Drugs (Buy-and-Bill)
Need to verify outpatient medical drug authorization requirements?
Medical Benefit Prior Authorization & Appeals
| Plan | Phone | Fax |
|---|---|---|
| Medicaid / Partnership In Care (SNP) / Enhanced (HARP) | 1-800-303-9626 | 1-212-908-5178 |
| Child Health Plus | 1-800-303-9626 | 1-212-908-5178 |
| Essential Plan | 1-855-809-4073 | 1-212-908-5178 |
| Gold / Gold Care | 1-800-303-6326 | 1-212-908-5178 |
| Marketplace & QHP | 1-855-809-4073 | 1-212-908-5178 |
| Medicare / UltraCare | 1-866-986-0356 | 1-212-908-5178 |
Provider Portal
Submit medical benefit authorization requests electronically through the MetroPlusHealth Provider Portal.
- Faster processing
- Upload clinical documentation
- Track request status
Additional Resources
Pharmacy Partners
We partner with more than 500 pharmacies, some open 24-hours, across all five boroughs including:
CVS Pharmacy
Duane Reade
More than 400 independent, community pharmacies
Delivery services are also available from CVS’s Caremark and other in-network pharmacies, although some pharmacies may charge a delivery fee on their end.
Looking for a pharmacy that partners with MetroPlusHealth AND fits your specific needs? Click here
An important note: As of April 1, 2023, all members enrolled in MetroPlusHealth Medicaid, Partnership In Care, and Enhanced (HARP) plans will receive their prescription drugs through NYRx, the Medicaid Pharmacy Program.
Want to learn more? Find more information about NYRX for providers here and get answers to frequently asked questions here.
We Offer 90-Day Refills!
Does MPH cover mail-order pharmacies?
Yes! Delivery services are also available from CVS’s Caremark and other in-network pharmacies, although some pharmacies may charge a delivery fee on their end.