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NYS Medicaid Pharmacy Prior Authorization Programs

Providers • PDP • About

Medicaid Pharmacy Preferred Drug Program

Introduction

The Medicaid Preferred Drug Program (PDP) promotes the use of less expensive, equally effective prescription drugs when medically appropriate. Preferred drug programs are used in the private sector, in other state Medicaid programs and in the Medicare Part D drug program. The Department of Health has contracted with Magellan Medicaid Administration, Inc. to assist with management of the PDP.

All drugs currently covered by Medicaid remain available under the PDP and the determination of preferred and non-preferred drugs does not prohibit a prescriber from obtaining any of the medications covered under Medicaid.

Overview

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. The DURB also makes clinical recommendations to the State on which drug(s) should be considered for the Clinical Drug Review Program (CDRP) and what the criteria should be for obtaining a drug.

Additional responsibilities of the DURB include:

  • The establishment and implementation of medical standards and criteria for the retrospective and prospective DUR program.
  • The development, selection, application, and assessment of educational interventions for physicians, pharmacists and recipients that improve care.
  • The collaboration with managed care organizations to address drug utilization concerns and to implement consistent management strategies across the fee-for-service and managed care pharmacy benefits.

DURB meetings are held in a public forum. Information on upcoming board 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.

The Preferred Drug List (PDL) is available as a downloadable PDF file, or by calling 1-877-309-9493.

Prior Authorization

Most preferred drugs are available without prior authorization.

The PDP prior authorization process features a staffed call center which is available 24 hours a day, 7 days per week. Guidelines on how to obtain prior authorization for drugs identified as non-preferred are available online at http://newyork.fhsc.com/providers/PDP_forms.asp.

For questions and comments: