Pharmacy Services

Pharmacy Services

Total Care, A Today’s Options of New York Health Plan is contracted with Express Scripts to provide you with prescription drug coverage.  Our goal is to meet your needs and provide your medicines in a cost effective manner.   You can find our drug lists and special pharmacy services below.

Medicaid Prescription Drug Formulary

Over the Counter Product List

Behavioral Health Formulary Updates

Pharmacy Contact Information

  • Express Scripts Customer Service & Prior Authorization Center Phone Number: 1-800-753-2851

  • Express Scripts Prior Authorization Center Fax Number: 1-800-357-9577

  • Accredo Specialty Pharmacy: 1-877-222-7336

Pharmacy-Request for Prior Authorization

Total Care, A Today's Options® of New York Health Plan Members and Providers may request a Prior Authorization for a medication in one of the following ways:

Non-formulary and Formulary Drug Prior Authorization (PA) Request Process

A completed Prior Authorization (also known as a “PA”) may be required for a drug before it is reimbursed by the plan. This is often the case if a medication does not appear on the plan’s Preferred Drug List (also known as a “PDL”).  It also may be the case if a medication requires clinical documentation prior to its use.  If your medication requires a PA, a PA form will need to be completed by your doctor and submitted to Express Scripts for review and approval before you fill the prescription.

To obtain the PA form and a list of medications that require a PA, please contact the Express Scripts PA Center at 1-800-753-2851.

Please check the plan’s PDL for periodic updates. The plan reserves the right to make changes to the PDL (also known as drug formulary) or PA process at any time.

A PA is meant to encourage appropriate use of medications. Drugs that generally require PA are:

  • Those that are part of a step therapy regimen or have lower cost alternatives

  • Those that have the potential for a lot of side effects

  • Those that should be reserved for specific FDA indication

  • Those that have a high potential for misuse or abuse

The plan will require a PA if there is an FDA-approved generic equivalent of a brand name drug.  The purpose of this is to promote the usage  of generic alternatives as first-line therapies, when medically appropriate.

General Drug Formulary Information

Brand Name vs. Generic Medications

  • Brand-Name Medication: A brand-name medication is one that is developed, patented and marketed by the original drug manufacturer. Until the patent expires, no other companies can produce that same brand-name medication. Brand-name medications in the plan’s list of covered drugs are capitalized.

  • Generic Medication: A generic medication:

    • Has the same active ingredients as its brand-name counterpart.

    • May be manufactured by various drug companies after the brand-name medication’s patent expires.

    • Is identical to the brand-name medication in dosage form, strength, route of administration, quality and intended uses.

    Generic medications may differ from their brand-name medication equivalent in color and/or shape. Both brand-name medications and generic medications have to meet the same strict safety, purity and performance standards governed by the FDA.

Multi-Source
Prior to filling any multi-source brand, physicians are required to consider using its preferred generic alternative. A multi-source brand-name drug with a generic alternative requires a written PA for benefit coverage based on medical necessity.

Select medications on the PDL may require PA. Medication utilization must meet FDA-approved guidelines and the plan’s guidelines. If a medication requires PA, a PA form needs to be completed by the prescriber and submitted to Express Scripts.

Quantity Supply Limit
The quantity supply limit is the maximum amount of a drug that can be filled at the pharmacy at a given time.  The plan has a PA program that follows FDA-approved dosing guidelines.  In some cases, a prescribing provider may feel that it’s necessary to prescribe a quantity of a medication y  greater than what is considered medically necessary.  If this is the case the provider must submit a written PA in order to validate the medical rationale for exceeding the recommended dosage.

Dose Optimization
The dose optimization program identifies claims where multiple capsules or tablets of medication are being used each day.  The program encourages an optimal dose and, in some situations, a single daily dose. Claims submitted where the quantity of a medication exceeds the optimal dose without a PA will be rejected.

Specialty Pharmacy

You are able to fill certain specialty drugs at local retail pharmacies. You may continue to receive medications in the mail from Accredo, an Express Scripts Specialty Pharmacy.

If you want to fill your specialty drugs at a local retail pharmacy, contact the pharmacy to determine if they are or will participate in the Express Scripts Retail Specialty Drug Program for Total Care, A Today's Options® of New York Health Plan Members. Not all local pharmacies take part in this program.

If you have any questions about the Accredo Specialty Drug Pharmacy please contact Accredo at 1-877-222-7336.

If you’re a provider, you do not have to take any additional steps for your patients to continue being serviced by.

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