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New York State Medicaid Fee-for-Service (FFS) Pharmacy Prior Authorization Programs Presented by: Magellan Medicaid Administration, Inc. & New York State.

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Presentation on theme: "New York State Medicaid Fee-for-Service (FFS) Pharmacy Prior Authorization Programs Presented by: Magellan Medicaid Administration, Inc. & New York State."— Presentation transcript:

1 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

2 Overview  What are the Medicaid FFS Pharmacy Prior Authorization (PA) Programs?  How do I obtain Prior Authorization?  Where can I go for more information? 2

3  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? 3

4 Preferred Drug Program (PDP) Implemented June 28, 2006 4

5 Preferred Drug Program (PDP)  Clinically driven & evidence-based  Maintains access to all drugs  Competitive pricing through supplemental rebates  Savings offset high drug costs 5

6 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 6

7 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) 7

8 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 8

9  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:  DUR Programs 9

10  S ystem 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 10

11 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:  11

12 Clinical Drug Review Program (CDRP) Implemented October 18, 2006 12

13 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 13

14 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 ) 14

15 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 ® 15

16 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 16

17 Mandatory Generic Drug Program (MGDP) Implemented November 17, 2002 17

18 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 ® 18

19 Preferred Diabetic Supply Program (PDSP) Implemented October 1, 2009 19

20 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 20

21 How Do I Obtain Prior Authorization? 21

22 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 22

23 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 23

24 Where Can I Go for More Information? 24

25 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 25

26  PDL  PSL  Prior authorization fax form and worksheets  Clinical criteria  Material for enrollees 26

27  Medicaid Update monthly publication  NYS health insurance & pharmacy programs  DUR Board  27

28  Formulary finder file  Provider enrollment forms & manuals  Patient eligibility verification instructions  Billing information  Fraud alerts 28

29 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 29

30 New York State Medicaid Prior Authorization Programs 30 Questions and Discussion

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