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NYS Medicaid Pharmacy Prior Authorization Programs

Frequently Asked Questions

Frequently Asked Questions

General / Prior Authorization Questions
Drug Utilization Review Board Questions
Clinical Drug Review Program Questions
Mandatory Generic Drug Program Questions
Preferred Drug Program / Preferred Drug List Questions
Brand Less Than Generic Program Questions

General / Prior Authorization Questions

Which enrollees are affected by the Medicaid Pharmacy Prior Authorization programs?

All enrollees who receive pharmacy services through the Medicaid fee-for-service program are affected by these programs.

How does the Medicaid Pharmacy Prior Authorization Programs affect enrollees that are also eligible for Medicare (dual eligibles)?

NYS Medicaid provides limited coverage of prescription vitamins and benzonatate products to beneficiaries who are also enrolled in Medicare Part D. NYS Medicaid will also cover certain over-the-counter drugs for these beneficiaries. Coverage of these products are subject to the NYS Medicaid Prior Authorization Program criteria.

For information regarding Medicare drug benefits, contact Medicare at 1-800-MEDICARE. Questions pertaining to Medicaid drug coverage may be directed to 1-518-486-3209.

Can a prescriber or authorized agent ask for more than one prior authorization at the same time or do they have to call back for each prescription?

Multiple authorizations can be received through one phone call. You can get more than one prior authorization for the same enrollee or authorizations for more than one enrollee during the same call.

What happens to an enrollee who gets to the pharmacy and is told that they need a prior authorization approval to get their prescription?

The pharmacist may contact the prescriber who may then choose to change the prescription to another drug or use the prior authorization system. Enrollees may also contact their prescriber to discuss their prescription.

What happens if the pharmacy cannot reach the prescriber for a prior authorization approval, and the enrollee needs the medication right away?

If the enrollee has a valid prescription, the pharmacist may provide the enrollee with up to a three (3)-day emergency supply of the medication by completing the emergency prior authorization process.

Who can request a prior authorization?

In most cases, an authorized agent of the prescriber can request 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). Some drugs require that prescribers, not their authorized agents, initiate the prior authorization process.

Are prescribers able to obtain a prior authorization for enrollees with a temporary Medicaid ID card?

No. The pharmacist will not be able to adjudicate the claim online until the eligibility is posted on the Medicaid eligibility file.

Can medical residents or physician assistants use the institution or clinic NPI number when requesting a prior authorization?

No. An institution or clinic NPI number will not be accepted.

Once a 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 at the clinical call center?

The clinical call center operates 24 hours per day, 7 days per week.

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Drug Utilization Review Board Questions

What are the responsibilities of the Drug Utilization Review Board (DURB)?

Pursuant to state law, the DURB was created to establish and implement medical standards and criteria for Medicaid's DUR programs.

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.
  • The review of therapeutic classes subject to the Preferred Drug Program (PDP).

What is the make-up of the NYS Medicaid Drug Utilization Review Board (DURB)?

The DURB is comprised of physicians and pharmacists who actively practice in New York, consumer representatives, health care economists and financial experts, all appointed by the Commissioner of Health.

How often does the DUR Board meet?

The schedule for the DURB varies. Meeting agendas and summaries are provided on the DURB website. DURB meetings are posted on the website thirty days prior to the meeting date.

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.

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Clinical Drug Review Program Questions

What is the Medicaid CDRP?

The Clinical Drug Review Program is a prior authorization program aimed at ensuring specific drugs are utilized in a clinically appropriate manner. Under the CDRP, certain drugs require prior authorization because there may be particular safety issues, public health concerns, the potential for fraud and abuse or the potential for significant overuse and misuse.

How is the CDRP established?

Drugs that are managed by the CDRP are reviewed by the State to determine inclusion into the CDRP. The NYS Drug Utilization Review Board (DURB) makes clinical recommendations to the State on which drug(s) should be considered and what the criteria should be for obtaining a drug. The Commissioner of Health issues final determinations based on the recommendations of the DURB.

How are providers informed of changes to the CDRP?

All changes to the CDRP will be communicated to providers via the monthly Medicaid Update publications. Sign up to receive e-mail notifications.

What drugs are subject to the CDRP?

The following drugs are currently subject to this program:

What Preferred Drug Program (PDP) drug classes are subject to the CDRP?

The following PDP drug classes are subject to this program:

Which drugs managed by the CDRP require that the prescriber initiate the prior authorization process?

The following drugs require that the prescriber initiate the prior authorization process:

  • Adcirca®
  • Growth Hormones (for enrollees 21 years of age or older)
  • Revatio
  • Serostim®
  • Sivextro®
  • Synagis®
  • Xyrem®
  • Zyvox®

How is prior authorization for a CDRP drug obtained?

All prior authorization (PA) requests should be directed to the prior authorization clinical call center at 1-877-309-9493. Prescribers may be required to provide specific clinical information. Prior authorization worksheets are available on the website.

How do I know which enrollees are subject to the CDRP?

All enrollees who receive pharmacy services through the Medicaid fee-for-service program are subject to the CDRP.

Mandatory Generic Drug Program Questions

What products are subject to the Mandatory Generic Drug Program?

Brand name prescription drugs for which an A-rated therapeutic and generic equivalent has been approved by the federal Food and Drug Administration (FDA). These are listed in the "Approved Drug Products with Therapeutic Equivalence Evaluations" (Orange Book). The list of drugs exempt from this requirement can be found at http://www.health.state.ny.us/health_care/medicaid/program/mandatory_generic/index.htm.

Which enrollees are affected by this program?

All prescriptions for enrollees who are covered under the Medicaid fee-for-service program are subject to this requirement.

Can categories of patients, rather than just individual drugs, be exempted from the mandatory generic program?

No, we do not have the legal authority for such an approval.

How do I know if the generic version has been "A-rated" or not?

The very large majority of generic products approved by the FDA are A-rated. It's likely that the majority of brand name drugs with generics which you prescribe today are A-rated. When in doubt, you may check the FDA website, at www.fda.gov, or contact a pharmacist.

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Preferred Drug Program / Preferred Drug List Questions

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 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 drug. DURB meetings are held in a public forum. Information on upcoming DURB meetings are posted on the DURB website thirty days prior to each meeting.

Various drugs on the PDL have additional annotations. What are these?

The superscripts 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. In addition, some drugs will have footnotes for implementation dates that can be found on the bottom 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. Sign up to receive e-mail notifications.

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; such as the Clinical Drug Review Program or the Brand Less than Generic (BLTG) program.

If, after considering the products on the PDL, the physician still feels the enrollee needs a drug requiring prior authorization, what needs to be done?

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 enrollee's Medicaid ID number available. Prescribers should also be prepared to respond to questions about the enrollee's medical need for a product drug. Prior authorization requests 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. Medicaid enrolled prescribers can initiate prior authorization requests using a web-based application.

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Brand Less Than Generic Program 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. 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.

Is this program in conformance with New York State Education Law regarding generic substitution?

Yes, generic substitution intends that a less costly alternative be dispensed; brand name drugs included in this program have a generic co-payment and are less costly for the state.

Do brand name drugs included in this program require 'Dispense as Written' (DAW) or ‘Brand Medically Necessary’ on the prescription?

No. Prescription claims submitted to the Medicaid program do not require the submission of Dispense as Written/Product Selection Code of '1'; Pharmacies can submit any valid NCPDP field (408-D8) value.

Will the enrollee need to obtain a new prescription if the drug is removed from the Dispense Brand Drugs When Less Expensive Program?

No. A new prescription is not required if the generic alternative becomes the more cost effective option.

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