The New York State Medicaid Pharmacy Management Program

The New York State Medicaid Pharmacy Program covers medically necessary FDA approved prescription drugs. Prescription drugs require a prescription order with appropriate required information. Certain drugs require the prescriber to obtain prior authorization before a prescription can be dispensed.

There are three different Medicaid Pharmacy Management Programs: the Preferred Drug Program (PDP), the Mandatory Generic Drug Program (MGDP), and the Clinical Drug Review Program (CDRP). Prescribers obtain prior authorization for all these programs by calling the Medicaid Pharmacy Prior Authorization Clinical Call Center at 1-877-309-9493. Pharmacies must also call to validate.

All beneficiaries who receive pharmacy services through the Medicaid fee-for-service program are subject to the three pharmacy management programs. This includes Medicaid Managed Care members, Family Health Plus members, and Child Health Plus "A" members.

The Preferred Drug Program (PDP)

The PDP promotes the prescribing of less expensive, equally effective prescription drugs when medically appropriate. The Medicaid Pharmacy and Therapeutics (P&T) Committee reviews drug classes and makes recommendations to the Commissioner of Health regarding the selection of preferred and non-preferred drugs.

Preferred drugs are available without prior authorization. The prescriber, or their authorized agent, must call the clinical call center to initiate prior authorization for non-preferred drugs. They will be asked to provide identifying information and a clinical reason why the patient requires the non-preferred drug.

A complete list of preferred and non-preferred drugs with guidelines stating how to obtain drug prior authorization is available at https://newyork.fhsc.com or http:www.nyhealth.gov/health_care/medicaid/program/pharmacy.htm

The following drug classes are currently excluded from prior authorization requirements under PDP:

  • Atypical anti-psychotics
  • Anti-depressives
  • Anti-retrovirals used in the treatment of HIV/AIDS
  • Anti-rejection drugs used for the treatment of organ and tissue transplant

The Clinical Drug Review Program (CDRP)

The CDRP is a program designed to ensure medications are used in a medically appropriate manner. Under this program, certain drugs require prior authorization because there may be safety issues, public health concerns, the potential for fraud and abuse, or significant over use and misuse.

The following drugs are currently managed by the CDRP program. The drugs are Revatio, Serostim, and Zyvox. Additional drugs will be added to the list of drugs managed by the CDRP effective 7/30/08. They are Byetta, Fentora, Actiq, Lidoderm. Request for prior authorization of these drugs must meet specific clinical criteria and written documentation may be required from the prescriber. For certain drugs subject to the CDRP, only the prescriber, not their authorized agent, can initiate the prior authorization process.

The Mandatory Generic Drug Program (MGDP)

The MGDP is a program that promotes the use of generic medications when appropriate. With the exception of drugs subject to the Preferred Drug Program and other drugs exempt from the MGDP. State statute excludes Medicaid coverage of brand-name drugs when an A-rated generic drug is available, unless a prior authorization is obtained.

The prescriber, or their authorized agent, must call the clinical call center to initiate prior authorization for brand name drugs subject to the MGDP. They will be asked to provide the clinical reason why the patient requires the brand-name drug instead of the generic.

The following drugs are currently exempt from prior authorization requirements under the MGDP:

  • Coumadin
  • Gengraf
  • Sandimmune
  • Clozaril
  • Lanoxin
  • Dilantin
  • Neoral
  • Zarontin
  • Levothyroxine Sodium (Unithroid, Synthroid, Levoxyl)