New York State Medicaid Pharmacy Prior Authorization Programs

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New York State Medicaid Pharmacy Prior
Authorization Programs

• Non-provider Presentation
• Presented by
• First Health Services Corporation
• New York State Department of Health
• Revised August 2008

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Objectives

• What are the Medicaid Pharmacy Prior
  Authorization Programs?
• Whats new in Medicaid Pharmacy Prior
  Authorization Programs?
• Where can I go for more information?

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Who Manages the Programs?

• The NYS Department of Health (DOH)
• Office of Health Insurance Programs
• Bureau of Pharmacy Policy and Operations
• First Health Services Corporation (FHSC) is under
  contract to assist in the administration of the
  programs

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Who is Subject to the Pharmacy PA Programs?

• Enrollees of the following programs receive
  pharmacy services through NYS Medicaid Pharmacy
  Benefit Program
• Medicaid fee-for-service
• Medicaid Managed Care
• Child Health Plus A
• Family Health Plus (Effective October 1, 2008)

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What are the Medicaid Pharmacy Prior
Authorization Programs?
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Preferred Drug Program

• Implemented June 28, 2006

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Preferred Drug Program (PDP)

• Promotes the prescribing of less expensive and
  equally effective drugs when medically
  appropriate
• Medicaid Pharmacy Therapeutics (PT) Committee
• Reviews drug classes
• Makes recommendations to Commissioner of Health
• Develops the Preferred Drug List (PDL)

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Preferred Drug List (PDL)

• Over 40 Therapeutic Classes
• Preferred drugs do not require a prior
  authorization (PA)
• Non-Preferred drugs require a PA through the
  Clinical Call Center
• Telephone [phone]
• Fax [phone]

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What types of drugs are subject to the PDP?

• Drugs used to manage
• High blood pressure
• Cholesterol
• Osteoporosis
• Allergies and asthma
• Chronic pain
• Type II diabetes
• Epilepsy

• Certain Drugs for
• Hepatitis C agents
• Herpes virus
• Growth hormone deficiency
• Anemia
• Glaucoma
• Sleep

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Mandatory Generic Drug Program

• Implemented November 17, 2002

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Mandatory Generic Drug Program

• Promotes the use of generic medications when
  medically appropriate
• Certain drugs are currently exempt
• PDP drug classes are not subject to the program
• Brand name drugs require PA through the voice
  interactive phone system (VIPS) if there is an
  A-rated generic available

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Clinical Drug Review Program(CDRP)

• Implemented October 18, 2006

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Clinical Drug Review Program (CDRP)

• Ensures medications are used in a medically
  appropriate manner
• CDRP drugs require PA through the Clinical Call
  Center
• Drugs subject to CDRP

• Actiq
• Byetta
• Fentora
• Lidoderm

• Revatio
• Serostim
• Zyvox

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Whats new in NYS Medicaid Prior Authorization
Pharmacy Programs?
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Effective October 1, 2008

• Family Health Plus (FHPlus)
• The pharmacy benefit for FHPlus enrollees will be
  administered by the NYS Medicaid Program
• Prescriptions for FHPlus enrollees will be
  subject to Medicaid Pharmacy PA Programs
• Co-payments for FHPlus will not change

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Benefit Identification Card

• FHPlus enrollees
• Will receive a Benefit Identification Card in the
  mail
• Will continue to use their current FHPlus plan
  card for their pharmacy benefits until October 1,
  2008
• If a FHPlus enrollee is already using a Benefit
  Identification Card to obtain other benefits,
  they must use this same card for their pharmacy
  benefits after October 1, 2008

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FHPlus Pharmacy Benefits

• Prescription Drugs
• Insulin diabetic supplies
• Smoking cessation agents
• Select over-the-counter (OTC) medications
• Hearing aid batteries
• Enteral formula

Subject to the Pharmacy PA Programs
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Where can I go for more information?
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https//newyork.fhsc.com

• Information on the PA Programs
• Preferred Drug List
• Material for enrollees

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www.nyhealth.gov

• Medicaid Update monthly publication
• Pharmacy program information
• PT Committee information
• FHPlus program information

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Important Phone Numbers

• Family Health Plus [phone]
• Medicaid Helpline [phone]
• Enrollees [phone]
• Pharmacy Policy [phone]
• Prior Authorization Call Center [phone]

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Take Away Points

• Preferred drugs do not require a PA
• Many resources are available online
• Sign up today and receive updates via email
• NYPDPNotices_at_firsthealth.com

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New York State MedicaidPrior Authorization
Programs