SMMC 3.0 Transition: Pharmacy Continuity of Care
Updated: Oct 17
The Agency for Health Care Administration (Agency) contracts with health and dental plans to provide Medicaid services to health plan enrollees. The Agency recently entered into new contracts with health and dental plans effective February 1, 2025. Under the new Statewide Medicaid Managed Care (SMMC) contracts, plans are still required to ensure continuity of care (COC) during the transition period for Medicaid recipients enrolled in the SMMC program.
To ensure a smooth transition of enrollees from the fee-for-service (FFS) delivery system or a health plan to another health plan, the Agency fiscal agent pharmacy system will support point of sale messaging to all pharmacies attempting to process claims during the transition period. To ensure no disruption in current services, health plans will allow enrollees to continue to receive their prescriptions through their current provider, for a minimum of 90 days, until their prescriptions can be transferred to a provider in the plan’s network.
The Florida Statewide Medicaid Managed Care (SMMC) 3.0 transition makes pharmacy continuity of care an important issue for Medicaid recipients, caregivers, pharmacies, and healthcare providers. During a managed care transition, recipients should verify that their prescriptions, preferred pharmacies, and medication coverage remain accessible under their new or continuing health plan. Changes to pharmacy networks, prescription formularies, prior authorization requirements, or prescription refill procedures may create delays if not addressed early.
Florida Medicaid recipients should contact their health plan to confirm prescription coverage, check whether medications require prior authorization, and ask how to obtain refills during the transition. Pharmacies and providers can help reduce disruptions by verifying eligibility, reviewing prescription requirements, and coordinating with the plan when coverage questions arise. Anyone experiencing difficulty obtaining a needed medication should contact their plan promptly and ask about applicable continuity-of-care protections or transition procedures.
Pharmacy Continuity of Care and Urgent Prescriptions
The Florida Statewide Medicaid Managed Care (SMMC) 3.0 transition makes pharmacy continuity of care important for Medicaid recipients, caregivers, pharmacies, and healthcare providers. Changes to health plans, pharmacy networks, prescription formularies, or prior authorization requirements may interrupt access to medications. Recipients should confirm prescription coverage and participating pharmacies with their current or new Medicaid managed care plan.
What to Do if You Need an Urgent Prescription
Call your pharmacy. Explain that you are a Florida Medicaid recipient experiencing a plan transition and need your medication urgently. Ask whether your prescription can be processed under your current coverage.
Contact your Medicaid health plan. Use the member services number on your insurance card. Explain the medication access problem and ask about emergency supplies, transition-of-care procedures, or an expedited review, if applicable.
Ask about prior authorization. If coverage is delayed because approval is required, ask your prescriber and health plan how to request urgent authorization.
Contact your prescriber. Ask the prescribing healthcare professional to coordinate with the pharmacy and health plan or determine whether a clinically appropriate alternative is available.
Keep records. Document calls, reference numbers, denial notices, and instructions received from the plan or pharmacy.
Do not stop a prescribed medication or change your dose without medical advice. If missing a dose could cause serious harm, contact your prescriber or pharmacist immediately. For a medical emergency, call 911 or go to the nearest emergency department.
Florida Medicaid recipients should verify current transition dates, pharmacy coverage, and applicable continuity-of-care protections with the Florida Agency for Health Care Administration (AHCA) and their health plan.
Florida Medicaid Pharmacy Help: Who to Contact
If you are having trouble filling a prescription during the Florida Medicaid SMMC 3.0 transition, contact the appropriate organization for assistance.
Your Medicaid health plan: Call the Member Services number on your Medicaid plan ID card. Ask about covered medications, participating pharmacies, emergency prescription supplies, prior authorization, and urgent medication access.
Your pharmacy: Ask the pharmacist to verify your Medicaid eligibility, confirm your plan's pharmacy coverage, and identify the reason your prescription cannot be processed.
Your prescribing healthcare provider: Contact your doctor or other prescriber if a medication requires prior authorization, a new prescription, or an alternative treatment.
Florida Medicaid and AHCA: Visit the Florida Agency for Health Care Administration (AHCA) website for official Medicaid program information and resources.
What Information Should You Have Ready?
Before calling, prepare your Medicaid ID number, health plan name, medication name and dosage, pharmacy contact information, and any denial or prior authorization details.
Need medication urgently? Tell the pharmacy and health plan that the prescription is time-sensitive. Ask what immediate options are available under your plan's current policies.
Emergency supplies and coverage exceptions are not guaranteed, so request specific instructions. If missing a dose could be dangerous, contact your prescriber or pharmacist promptly. For a medical emergency, call 911.
Related Article
Florida Medicaid SMMC 3.0: Benefits, Health Plans, Regions, and Recipient Guide
Florida Medicaid's Statewide Medicaid Managed Care (SMMC) 3.0 program introduced new health and dental plan contracts effective February 1, 2025. The program affects how many Florida Medicaid recipients access healthcare, choose managed care plans, receive long-term care services, and obtain dental benefits.
Whether you are applying for Medicaid, already enrolled in a health plan, caring for a family member, or providing healthcare services, understanding SMMC 3.0 can help you navigate coverage and resolve problems more effectively. Click here to read the full article.
Conclusion
Verify your Medicaid plan's pharmacy rules and seek help promptly to prevent prescription interruptions.
Disclaimer
This article is for informational purposes only. Verify current pharmacy rules with Florida Medicaid or your plan. Full disclaimer.
Love this article and the additional insight it provides our members! 👍
As a Florida Medicaid recipient, I hope SMMC 3.0 finally improves provider access and care coordination. The system needs less red tape and more real support.👍