New York State Medicaid
Fee-for-Service (FFS)
Pharmacy
Prior Authorization
Programs
Presented by:
Magellan Medicaid Administration, Inc.
&
New York State Department of Health (DOH)
Revised March 2014
Overview
 What are the Medicaid FFS Pharmacy Prior
Authorization (PA) Programs?
 How do I obtain Prior Authorization?
 Where can I go for more information?
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Who is Subject to the FFS Pharmacy PA
Programs?
 Enrollees of the following program receive
pharmacy services through NYS Medicaid
Pharmacy Benefit Programs
 Medicaid Fee-For-Service
 Approximately 1.5 million people
 Will continue to present their Medicaid card at the pharmacy
 Will continue to receive their pharmacy benefits from Medicaid
until such time that they are moved into managed or care
management
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Preferred Drug Program (PDP)
Implemented June 28, 2006
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Preferred Drug Program (PDP)
 Clinically driven & evidence-based
 Maintains access to all drugs
 Competitive pricing through supplemental
rebates
 Savings offset high drug costs
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Preferred Drug List (PDL)
 Categorized by therapeutic drug class
 Preferred and non-preferred drugs
 Footnotes provide useful information
 Developed by the Drug Utilization Review (DUR)
Board
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DUR Board Meetings
 Committee Members
 Practicing physicians, nurse practitioners, pharmacists
and patient advocates
 Make recommendations on preferred status within PDP
drugs classes
 Review of existing therapeutic classes
 Newly FDA-approved drugs
 Addition of new therapeutic classes
 Review and develop clinical criteria for PDP and the Clinical
Drug Review Program (CDRP)
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DUR Board Meetings
 Public session announced on DOH website
 Clinical Evidence & Discussion
 Healthcare professionals
 Drug Effectiveness Review Project (Oregon Health & Sciences

University)
Pharmaceutical manufacturers and other interested parties
 Executive Session
 Financial information is considered only after the clinical discussion
is completed
 Committee formulates recommendations
 Commissioner of Health makes the final determination
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DUR Programs
 Programs to help ensure that prescriptions for
outpatient drugs are appropriate, medically
necessary, and not likely to result in adverse medical
consequences:
 Step Therapy Program
 Frequency/Quantity/Duration (F/Q/D) Program
 Dose Optimization Program
 DUR edits can be reviewed on the PDL:

https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf
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DUR Programs
 System editing will be performed at the point-of-sale to
allow claims to pay without prior authorization when
clinical criteria and F/Q/D limits are met
 An automated approval will be issued if all rules
associated with the requested product are satisfied; which
will result in a paid claim
 A failed clinical rule will result in a failed claim
 A rejection message will be provided at the point-of-sale
instructing pharmacy providers to notify the prescriber to change
the prescription if appropriate or to obtain prior authorization
 Prescribers must obtain prior authorization through the
clinical call center for claims that do not meet clinical
criteria
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Brand When Less than
Generic Program
 Promotes the use of multi-source brand name drugs when
the cost of the brand name drug is less expensive than the
generic
 Do not require “DAW” or “Brand Medically Necessary” on
the prescription
 Please visit the following website for recent news and a
listing of drugs subject to the program:

https://newyork.fhsc.com/providers/bltgp_about.asp
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Clinical Drug Review Program
(CDRP)
Implemented October 18, 2006
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Intent of CDRP
 To ensure that certain drugs are utilized in a
medically appropriate manner
 To protect the long-term efficacy of certain drugs
and the public’s health
 To prevent overuse, abuse and illegal utilization of
certain drugs
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Drugs/Classes Subject to CDRP
An authorized agent* of the prescriber may initiate PA for the
following:
 Anabolic Steroids
 Central Nervous System (CNS) Stimulants for age 18 & older
 Fentanyl Mucosal Agents
 Lidoderm®
 Regranex®
 Topical Immunomodulators
 Truvada ®
*An authorized agent is an employee of the prescribing practitioner and has access to the patient's medical
records (i.e. nurse, medical assistant )
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Drugs/Classes Subject to CDRP
The prescriber must initiate PA for the following:

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
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Growth Hormones for age 21 years & older
Phosphodiesterase type-5 (PDE-5) Inhibitors for PAH
Serostim®
Synagis®
Xyrem®
Zyvox®
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Additional CDRP Information
 Defined clinical criteria has been established
 Fax requests are not permitted for some CDRP drugs
 PA requests may need to be escalated to the provider
for additional information
 Supporting documentation may be required for certain
PA requests
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Mandatory Generic Drug Program
(MGDP)
Implemented November 17, 2002
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Mandatory Generic Drug Program
 Originates from State statute which excludes Medicaid
coverage of brand name drugs when an A-rated generic is
available unless PA is obtained
 Drugs subject to the PDP, CDRP and/or the Brand when
Less Than Generic Initiative are not subject to this
program
 The following brand name drugs are exempt and do NOT
require PA:

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Clozaril®
Coumadin®
Dilantin®
Gengraf®
Lanoxin®

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
Levothyroxine Sodium
(Unithroid®, Synthroid®, Levoxyl®)
Neoral®
Sandimmune®
Tegretol®
Zarontin®
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Preferred Diabetic Supply Program
(PDSP)
Implemented October 1, 2009
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Preferred Diabetic Supply Program
 Preferred blood glucose monitors and corresponding
test strips are available without prior approval or
dispensing validation system (DVS) authorization
 “Talking” and disposable blood glucose monitors are
NOT included in the PDSP and will continue to be
covered by Medicaid through the existing prior
approval process
 Preferred Supply List (PSL) is available online
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How Do I Obtain Prior
Authorization?
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PDP, MGDP & CDRP PA Process
 Dial (877) 309-9493 and select option #1, then option #1
 Use the telephone key pad to enter:
 Prescriber NPI
 Prescriber Phone Number
 Certified Pharmacy Technician will assist in completing PA
 Faxing of PA requests to (800) 268-2990 is available for
PDP and some CDRP drugs
 PAs can be obtained 24 hours a day, 7 days a week
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DUR Program & PDSP PA Process
 Drug Utilization Review Program
 Dial (877) 309-9493 and follow appropriate
prompts
 Preferred Diabetic Supply Programs
 Dial (800) 342-3005 to reach NYS DOH
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Where Can I Go for More
Information?
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Program Updates Will be Communicated
Through:
 Email Notifications
 Program Updates
 Medicaid Update Article
 Mailings
 May be sent to prescribers most affected by program
updates to minimize practice impact
 Website Updates
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https://newyork.fhsc.com
 PDL
 PSL
 Prior authorization fax form and worksheets
 Clinical criteria
 Material for enrollees
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www.nyhealth.gov
 Medicaid Update monthly publication
 NYS health insurance & pharmacy programs
 DUR Board
 http://www.nyhealth.gov/health_care/medicaid/program/dur/
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www.emedny.org
 Formulary finder file
 Provider enrollment forms & manuals
 Patient eligibility verification instructions
 Billing information
 Fraud alerts
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Important Numbers
 Clinical Call Center: (877) 309-9493
 Clinical Call Center Fax: (800) 268-2990
 Diabetic Supply Prior Approval line: (800) 342-3005
 Pharmacy Policy: (518) 486-3209
 Enteral formula PA line: (866) 211-1736
 Billing: (800) 343-9000
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New York State Medicaid
Prior Authorization Programs
Questions and Discussion
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