New NY Managed Medicaid RX Rule Issue Form

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A key part of the New York City Hemophilia Chapter's mission is to ensure that the bleeding disorders community has access to comprehensive health care and accessible pharmacies throughout New York State.

Beginning on July 1, 2019, patients with NY Managed Medicaid Plans are being covered by a new pharmacy rule. The new rule may change where patients with Managed Medicaid can get clotting factor. You can find more information regarding this new pharmacy rule below:

https://www.nyhemophilia.org/new-managed-medicaid-rx-rule-faq/

This form is intended to help patients with Managed Medicaid plans that have been affected or have had problems with the new pharmacy rule. Please keep in mind - THIS FORM IS ONLY FOR COMMUNITY MEMBERS WHO HAVE MANAGED MEDICAID THROUGH NEW YORK STATE.

Regards,
The New York City Hemophilia Chapter Team

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Please indicate the patient for whom you are completing this form: If you are completing this form for someone other than yourself: (a) you must seek permission from that person, (b) you may not provide their name or contact information without their express permission, (c) “I/my/you/your” for the duration of the survey refers to the patient for which you filling out the form, and (d) * will indicated that the field is required. *

Myself

A family member who is a child under the age of 18

A family member who is an adult 18 years or older

A patient I service who is a child under the age of 18

A patient I service who is an adult 18 years or older

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