NYS Medicaid Pharmacy Prior Authorization Programs
Providers • PDP • FAQs - Providers & Prescribers
Preferred Drug Program Frequently Asked Questions - Providers & Prescribers
Listed below are some of the most commonly asked questions about the Preferred Drug Program. 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 is the PDL established?
- What is the make-up of the NYS Medicaid Drug Utilization Review Board (DURB)?
- How often does the DUR Board meet?
- How often does the DUR Board review their previous recommendations?
- Various drugs on the PDL have a footnote attached to them. What is this?
- How are providers updated about changes to the PDL?
- Will Medicaid make the PDL available to prescribers in a more accessible electronic format?
- Are all drugs that NYS Medicaid covers subject to the PDP?
Prior Authorization FAQs
- If, after considering the products on the PDL, I still feel my patient needs a drug requiring prior authorization, what do I do?
- What are the hours of the clinical call center?
- How long does the prior authorization process take?
- Who can request a prior authorization?
- Once prior authorization is approved, how long is it valid for?
- Which enrollees are affected by this program?
- How does the PDP affect enrollees that are also eligible for Medicare (dual eligibles)?
- What if I have more questions?
- What is the Brand Less than Generic Program?
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 is the PDL established?
The 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. DURB meetings are held in a public forum. Information on upcoming committee meetings are posted on the DURB thirty days prior to each meeting.
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.
How often does the DUR Board meet?
The schedule for the DURB varies. Dates of the meetings and Agendas are listed on the DUR website.
How often does the DUR Board review their previous recommendations?
The DURB reviews any new clinical or financial information for each therapeutic class subject to the PDP annually. Due to the number of classes included on the PDL, the reviews are completed during multiple meetings.
Various drugs on the PDL have a footnote attached to them. What is this?
The footnote indicates that there are additional clinical criteria, step edits, or frequency/quantity/duration edits associated with certain drugs or drug classes. Explanations for the footnotes are provided on the right-hand column of the PDL.
How are providers updated about changes to the PDL?
All changes to the New York Medicaid PDL will be communicated to providers via the monthly Medicaid Update publications. If you would like to receive e-mail notifications click here.
Will Medicaid make the PDL available to prescribers in a more accessible electronic format?
In response to requests from the prescribing community, DOH is exploring options on how to make the PDL more accessible to providers.
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; for example the Mandatory Generic Drug Program or the Clinical Drug Review Program.
Prior Authorization FAQs
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/.
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 requests 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.
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.
Which enrollees are affected by this program?
All enrollees who receive pharmacy services through the Medicaid fee-for-service program are affected by this program. Children's Medicaid enrollees are also subject to PDP. Child Health Plus enrollees receive medications through their managed care plan and are not subject to the PDP.
How does the PDP affect enrollees that are also eligible for Medicare (dual eligibles)?
Effective October 1, 2011, the Medicaid program will no longer cover drugs in the following drug classes when billed for full benefit Medicare/Medicaid dual eligibles:
- Atypical antipsychotics;
- Antiretrovirals used in the treatment of HIV/AIDS; and
- Antirejection drugs used for tissue and organ transplants.
Drugs in these classes must be billed directly to the Medicare/Medicaid enrollee's Part D plan, or when applicable, to Medicare Part B. Prior authorization or exception requests may be required by the Part D plan. The New York State Medicaid Program will continue to cover certain drugs which are excluded from the Medicare Part D benefit, such as barbiturates, benzodiazepines, some prescription vitamins and some non-prescription drugs. These drugs may continue to be billed directly to Medicaid. Prescribers and pharmacists are strongly encouraged to work with Medicare Part D plans prior to October 1, 2011, to obtain coverage of these drugs and avoid interruption in their patients' drug therapy.
For information regarding Medicare drug benefits, contact Medicare at 1-800-MEDICARE. Questions pertaining to Medicaid drug coverage may be directed to (518) 486-3209.
What if I have more questions?
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. For additional information visit: http://www.health.ny.gov/health_care/medicaid/program/pharmacy.htm. 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.