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NYS Medicaid Pharmacy Prior Authorization Programs

Providers • MGDP • FAQs

Mandatory Generic Drug Program Frequently Asked Questions

Listed below are some of the most commonly asked questions about the Mandatory Generic Drug Program (MGDP). If you do not find the information you need, please submit your question using the Contact Us form.

General FAQs

Prior Authorization FAQs


General FAQs

How does the program affect my practice?

When you prescribe generic drugs, there is no additional Medicaid requirement, and no impact on your practice. Prior authorization is required when you write the prescription for a brand name drug when there is a generic equivalent available.

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What products are subject to the Mandatory Generic Drug Program?

Brand name prescription drugs for which an A-rated therapeutic and generic equivalent has been approved by the federal Food and Drug Administration (FDA). These are listed in the "Approved Drug Products with Therapeutic Equivalence Evaluations" (Orange Book). The list of drugs exempt from this requirement can be found at http://www.health.state.ny.us/health_care/medicaid/program/mandatory_generic/index.htm.

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Can categories of patients, rather than just individual drugs, be exempted from the mandatory generic program?

No, we do not have the legal authority for such an approval.

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How do I know if the generic version has been "A-rated" or not?

The very large majority of generic products approved by the FDA are A-rated. Its likely that the majority of brand name drugs with generics which you prescribe today are A-rated. When in doubt, you may check the FDA website, at www.fda.gov, or contact a pharmacist.

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Do my patients know about this program?

Providers and associations are provided with educational information for distribution and discussion with patients: https://newyork.fhsc.com/enrollees/MG_brochures.asp. A supply of brochures can be ordered via this website or by sending a request to NYPDPNotices@magellanhealth.com.

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Which enrollees are affected by this program?

All prescriptions for enrollees who are covered under the Medicaid fee-for-service program are subject to this requirement.

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Does this program apply to prescriptions written and filled in an emergency room?

Yes, if the prescription is filled at a pharmacy which will be billing Medicaid (outpatient pharmacy).

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What is the Brand Less than Generic Program?

The Brand Less than Generic Program is a cost containment initiative which promotes the use of certain multi-source brand name drugs when the cost of the brand name drug is less expensive than the generic equivalent. Generic drugs included in this program require prior authorization. Once it is determined that the generic drug is more cost-effective than the brand name equivalent, the prior authorization requirement will be removed for the generic drug. Please keep in mind that multi-source brand name drugs may be included in the Mandatory Generic Drug Program; again promoting the use of the most cost-effective product.

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Prior Authorization Process FAQs:

How long does it take to do a prior authorization?

About three minutes.

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Can I ask for more than one prior authorization at the same time or do I have to call back for each prescription?

Multiple authorizations can be received through one phone call. You can get more than one prior authorization for the same patient or authorizations for more than one patient during the same call.

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What happens to a patient who gets to the pharmacy and is told that they need a prior authorization approval to get their prescription?

The pharmacist may contact the prescriber who may then choose to change the prescription to a generic drug or use the prior authorization system. Enrollees may also contact their prescriber to discuss their prescription.

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What happens if the pharmacy cannot reach the prescriber for a prior authorization approval, and the patient needs the medication right away?

If the patient has a valid prescription, the pharmacist may provide the patient with up to a three (3)-day emergency supply of the brand name drug by completing the emergency prior authorization process.

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What happens if an A-rated generic is unavailable for purchase in the marketplace?

In this case, the pharmacist must obtain a prior authorization for the brand name drug.

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Does the prescriber need to put "DAW" and "Brand Medically Necessary" in his/her own handwriting on the prescription?

No.

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What if the patient wants to get the brand name product?

The physician, rather than the patient, makes the decision as to the appropriate medication. The conversation with the patient may be a good opportunity for the physician to explain what generic products are, and why they might appear different (shape or color). The enrollee brochure may facilitate this discussion: https://newyork.fhsc.com/enrollees/MG_brochures.asp.

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Am I able to obtain a prior authorization for a patient with a temporary Medicaid authorization?

No. The Pharmacist will not be able to adjudicate the claim on line until the eligibility is posted on the Medicaid eligibility file.

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Can medical residents or physician assistants use the institution or clinic NPI number when requesting a prior authorization?

No. An institution or clinic NPI number will not be accepted.

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