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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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

Who is Subject to the FFS Pharmacy PA Programs?

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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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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

DUR Programs

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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

DUR Programs

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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 CDRPAn 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:

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:

Clozaril®

Coumadin®

Dilantin®

Gengraf®

Lanoxin®

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 MedicaidPrior Authorization Programs

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Questions and Discussion