NYRx, the Medicaid Pharmacy Program

About

The Preferred Drug Program (PDP) promotes the use of less expensive, equally effective prescription drugs when medically appropriate. The Department of Health has contracted with Prime Therapeutics State Government Solutions 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.

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 NYRx 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) contains a listing of drugs/classes that may be subject to NYRx Pharmacy Program specific criteria. Not all agents covered by NYRx are listed on the PDL. For a complete list of drugs covered by NYRx, visit the Medicaid Pharmacy List of Reimbursable Drugs.

Prior Authorization

• The PDP prior authorization process features a staffed call center which is available 24 hours a day, 7 days per week. To initiate the prior authorization process, the prescriber must call the prior authorization phone line at 1-877-309-9493 and select Option "2" for Prescriber.
• Questions and requirements will vary based on the drug being requested. The PDL contains additional information on clinical criteria.
• Fax requests are permitted for most drugs. Completed prior authorization forms should be sent to 1-800-268-2990. Fax requests may take up to 24 hours to process. Prior authorization forms and references are available online.

For questions and comments:

• For billing questions, call 1-800-343-9000.
• For clinical concerns or Preferred Drug Program questions, visit newyork.fhsc.com or call 1-877-309-9493.
• For Medicaid pharmacy policy and operations questions, call 1-518-486-3209.