NYS Medicaid Pharmacy Prior Authorization Programs
Providers • PDP • FAQs - Medical Residents
Preferred Drug Program Frequently Asked Questions - Medical Residents
Listed below are some of the most common questions that medical residents have about the Medicaid pharmacy prior authorization programs. If you do not find the information you need, please submit your question using the Contact Us form.
- What is the Medicaid Preferred Drug Program (PDP)?
- How are the drugs chosen for the PDP?
- What is the make-up of the NYS Medicaid Drug Utilization Review Board (DURB)?
- Are all drugs that NYS Medicaid covers subject to the PDP?
- Which enrollees are affected by this program?
- If, after considering the products on the PDL, I still feel my patient needs a drug requiring prior authorization, what do I do?
- Once prior authorization is approved, how long is it valid for?
- What are the hours of the Clinical Call Center?
- How long does the prior authorization process take?
- Who can request a prior authorization?
- What if I have more questions?
- My patient has managed care benefits, where do I call for an authorization?
What is the Medicaid Preferred Drug Program (PDP)?
The Medicaid Preferred Drug Program (PDP) promotes the prescribing of less expensive, equally effective prescription drugs when medically appropriate through the establishment of a Preferred Drug List (PDL). Drugs identified as “preferred” on the PDL can be obtained without prior authorization, unless otherwise indicated on the PDL.
How are the drugs chosen for the PDP?
The Drug Utilization Review Board (DURB) reviews drug classes and makes recommendations to the Commissioner of Health regarding the selection of preferred and non-preferred drugs within certain drug classes. They also recommend clinical criteria used to determine when it is appropriate to prior authorize a non-preferred drug. These recommendations are based on public comment and testimony, review of objective clinical research, then review of drug cost information.
DURB meetings are held in a public forum. Information on upcoming committee activities is posted on the web thirty days prior to each meeting. Public testimony and submission of information on drug classes to be discussed is encouraged.
What is the make-up of the NYS Medicaid Drug Utilization Review Board (DURB)?
The DURB is comprised of health care professionals appointed by the Commissioner and includes physicians and pharmacists that actively practice in New York.
Are all drugs that NYS Medicaid covers subject to the PDP?
Not all classes of drugs are subject to the PDP. However drugs in classes not included in the PDP may still be subject to other Medicaid requirements.
Which enrollees are affected by this program?
All enrollees who receive pharmacy services through the Medicaid fee-for-service program.
If, after considering the products on the PDL, I still feel my patient needs a drug requiring prior authorization, what do I do?
Prior authorization requests can be directed to the prior authorization clinical call center at 1-877-309-9493. Prescribers should have their identifying information ready, as well as the patient's Medicaid ID number available. Prescribers should also be prepared to respond to questions about the patient's medical need for a non-preferred drug. Guidelines on how to obtain prior authorization for drugs identified as non-preferred are available online at: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_procedures_for_prescribers.doc.
Prior authorization request for PDP drugs can also be faxed to the call center at 1-800-268-2990. Faxed request may take up to 24 hours to process. https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf.
Also, Effective September 6, 2012, Medicaid enrolled prescribers can initiate prior authorization requests using a web-based application. The website for PAXpress® is https://paxpress.nypa.hidinc.com/.
Once prior authorization is approved, how long is it valid for?
Prior Authorizations are valid for varying timeframes dependent upon the specific drug and drug utilization review edits implemented.
What are the hours of the Clinical Call Center?
The clinical call center operates 24 hours per day, 7 days per week.
How long does the prior authorization process take?
The average prior authorization request takes about 3 minutes. Faxed request can take up to 24 hours.
Who can request a prior authorization?
Only the prescriber or their authorized agent can request a prior authorization. An authorized agent is an employee of the prescribing practitioner and has access to the patient's medical records (i.e. nurse, medical assistant). Medicaid enrollees who call the clinical call center will be instructed to contact their prescriber to initiate prior authorization.
What if I have more questions?
My patient has managed care benefits, where do I call for an authorization?
Prescribers should contact the enrollee's MCO regarding the prior authorization process.