May 31, 2023
See important information below from OASAS.
Dear Providers,
As of April 1, 2023, Medicaid members enrolled in mainstream Managed Care (MC) plans, Health and Recovery Plans (HARPs), and HIV-Special Needs (SNPs) began receiving their pharmacy benefits through NYRx, the Medicaid Pharmacy Program.
To ensure a smooth transition for members, NYRx instituted a transition fill period from 4/1/23-6/30/23. During the transition period, members were provided a one-time transition fill for up to a 30-day supply of a drug that would normally require prior authorization (PA) under the NYRx Preferred Drug Program (PDP). This allowed additional time for prescribers to review the NYRx preferred drug list (PDL) and seek prior authorization or change to a preferred drug. In most cases, preferred drugs do not require prior authorization.
The one-time transition fill does not mean that a PA will not be required for future fills. Beginning on July 1, 2023, all claims will be subject to NYRx pharmacy program criteria listed on the NYRx PDL.
PAs issued by Medicaid Managed Care plans prior to April 1, 2023 (that are active/valid after April 1, 2023) will continue to be honored by NYRx. This includes clinical PAs that may also require PA under NYRx
What Prescribers Need to Do:
Prescribers should review the Preferred Drug List (PDL) and prescribe preferred products. Preferred products generally do not require prior authorization when prescribed according to FDA labeling.
What Pharmacy Providers Need to Do:
Pharmacies should become familiar with the PDL and incorporate this information when discussing the need for PA with prescribers. In most cases switching to a preferred drug will eliminate the need for prior authorization.
Pharmacies should refer to the NYRx Top Edit Resource for detailed information on claim edit denials and resources.
Resources:
Preferred Drug List
NYRx Education & Outreach Website
Thank you.