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 current Preferred Drug List (PDL) contains a listing of drugs/classes that may be subject to NYRx Pharmacy Program specific criteria. To view archived PDLs, visit the PDL Listing page. 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.

Preferred Drug Program (PDP) Prior Authorization Information

• The PDP call center is available 24 hours a day, 7 days a week.
• NYRx offers Three Ways to Submit a Prior Authorization to NYRx, the Medicaid Pharmacy Program, with electronic submission through CoverMyMeds® as the most effective option.
• Fax requests are permitted for most drugs. Please use the Prior Authorization Request Forms available online, send completed forms to 1-800-268-2990, and allow up to 24 hours for fax requests to be processed.
• Specific criteria requirements vary based on the drug being requested. You can find additional details on clinical criteria in the PDL.

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.