Pharmacy benefit transition monitoring by consumers and advocates, by Medicaid Matters New York
Este formulario está disponible en Español en este enlace. 

Medicaid Matters New York has been asked by the NYS Department of Health to participate in a "command center" to bring issues with the transition of the pharmacy benefit from Medicaid managed care to NYRx (fee-for-service Medicaid) to their attention.  The form below mirrors the form Medicaid Matters representatives have been asked to use, with the addition of a few demographic questions.

Should you or someone you work with experience any difficulty with accessing prescriptions after the April 1 transition date, please use this form to help us make sure the Department of Health is aware of issues happening as a result of the transition.  Please do not include any personal health information or other sensitive information in this form.

Consumers and advocates are encouraged to share this form widely for the reporting of pharmacy issues taking place as a result of the transition.

Anyone experiencing difficulty accessing prescriptions after April 1 should contact the NYS Department of Health Medicaid Helpline:
1-855-648-1909
TTY 1-800-662-1220
Hours are Monday - Friday, 8am-8pm and Saturday, 9am-1pm.
The Medicaid Helpline can connect callers to staff who speaks their preferred languages.

A copy of the letter that went to Medicaid enrollees to alert them of this change is linked here.
The NYS Department of Health's "What You Need to Know" fact sheet on the transition is linked here, in multiple languages.

If you have any questions, if you have any trouble completing this form, or you need the form to be provided in an accessible format, please contact Medicaid Matters Coalition Coordinator, Lara Kassel at lkassel@medicaidmattersny.org
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Name of individual completing the form: *
Email address of the individual completing this form: *
Issues identification date (date on which the issue was identified; can be approximate): *
MM
/
DD
/
YYYY
Issue identifier (the individual or organization who identified or raised the issue): *
Issue description (brief description of the issue): *
Impacted population (who is impacted by this issue?): *
If you selected "special populations" above, what special population is impacted (i.e. dual-eligible/have both Medicaid and Medicare, HIV/AIDS, children in foster care, people who have substance use disorder, etc.)? *
Approximately how many individuals do you estimate are impacted by the issue? *
In what managed care/insurance plan is/are the person/people enrolled in? *
In what county or counties did the issue take place? *
In what zip code did the issue take place? *
What is/are the race(s) of the person or people impacted by the issue? *
Required
What is the ethnicity of the person or people impacted by the issue? *
What is the primary or preferred language of the person or people impacted by the issue? *
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