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New York State Medicaid Fee-for-Service (FFS) Pharmacy Prior Authorization Programs PowerPoint Presentation
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New York State Medicaid Fee-for-Service (FFS) Pharmacy Prior Authorization Programs

New York State Medicaid Fee-for-Service (FFS) Pharmacy Prior Authorization Programs

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New York State Medicaid Fee-for-Service (FFS) Pharmacy Prior Authorization Programs

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  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 June 2013

  2. Overview Redesigning the Medicaid Program 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. Medicaid Redesign Team (MRT) Established in January 2011 Charged with reducing costs while increasing quality and efficiency in New York's Medicaid program Significant changes to pharmacy proposed and enacted as part of the 2011-2012 New York State (NYS) Budget Proposal #11 – Bundle Pharmacy into Medicaid Managed Care Proposal #15 – Reform the Medicaid FFS Program NYS Medicaid Redesign 3

  4. Medicaid Redesign Team (MRT) Proposal #11 Bundle Pharmacy into MedicaidManaged Care

  5. Effective October 1, 2011: Enrollees of the following programs no longer receive pharmacy services through NYS Medicaid FFS Pharmacy Benefit Programs Medicaid Managed Care Family Health Plus NYS Medicaid enrollees who are currently enrolled in managed care plans will also receive pharmacy benefits through their plans MRT Proposal #11 5

  6. 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? 6

  7. Medicaid Redesign Team (MRT) Proposal #15 Comprehensive Fee-For-Service Pharmacy Reform

  8. Effective December 29, 2011: Opioids limited to 4 prescriptions every thirty days Point of sale claim system will deny prescriptions for opioids that exceed this limit Prior Authorization available for medical necessity exceptions MRT Proposal #15 – Opioid Prescription Limits 8

  9. Effective December 29, 2011: Elimination of PA exemption for Atypical Antipsychotics Systems in place to allow patients stabilized on these products to continue therapy without obtaining PA New patient starts for non-preferred Atypical Antipsychotics will require PA MRT Proposal #15 – Atypical Antipsychotics 9

  10. Medicare Part D Dual Eligibles • Wrap around coverage for the following drug classes has been eliminated: • Atypical Antipsychotics • Antidepressants • Antiretrovirals • Immuno-Suppressants • Medicaid continues to cover certain drugs which are excluded from the Medicare Part D benefit: http://www.health.ny.gov/health_care/medicaid/program/medicaid_transition/docs/2013-01-01_medicare_exempt_drugs.pdf 10

  11. Preferred Drug Program (PDP) Implemented June 28, 2006 11

  12. Preferred Drug Program (PDP) Clinically driven & evidence-based Maintains access to all drugs Competitive pricing through supplemental rebates Savings offset high drug costs 12

  13. 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 13

  14. 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) 14

  15. 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 15

  16. Programs to help ensure that prescriptions for outpatient drugs are appropriate, medically necessary, and not likely to result in adverse medical consequences: Medicaid Pharmacy Step Therapy Program Medicaid Pharmacy Frequency/Quantity/Duration (F/Q/D) Program DUR edits can be reviewed on the PDL: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf DUR Programs 16

  17. 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 17

  18. 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 18

  19. Clinical Drug Review Program (CDRP) Implemented October 18, 2006 19

  20. 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 20

  21. 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 ® *In some cases, the prescriber will need to complete PA process 21

  22. 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® 22

  23. 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 23

  24. Mandatory Generic Drug Program (MGDP) Implemented November 17, 2002 24

  25. 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 doNOT require PA: • Levothyroxine Sodium (Unithroid®, Synthroid®, Levoxyl®) • Neoral® • Sandimmune® • Tegretol® • Zarontin® • Clozaril® • Coumadin® • Dilantin® • Gengraf® • Lanoxin® 25

  26. Preferred Diabetic Supply Program (PDSP) Implemented October 1, 2009 26

  27. 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 27

  28. How Do I Obtain Prior Authorization? 28

  29. 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 29

  30. DUR Program & PDSP PA Process Drug Utilization Review Programs Dial (877) 309-9493 and follow appropriate prompts Preferred Diabetic Supply Programs Dial (800) 342-3005 to reach NYS DOH 30

  31. Where Can I Go for More Information? 31

  32. Program Updates Will be Communicated Through: Email Notifications Program Updates Medicaid Update Article Mailings Sent to prescribers most affected by program updates to minimize practice impact Website Updates 32

  33. https://newyork.fhsc.com PDL PSL Prior authorization fax forms Clinical criteria Material for enrollees 33

  34. www.nyhealth.gov Medicaid Update monthly publication NYS health insurance & pharmacy programs DUR Board http://www.nyhealth.gov/health_care/medicaid/program/dur/ 34

  35. www.emedny.org Formulary finder file Provider enrollment forms & manuals Patient eligibility verification instructions Billing information Fraud alerts 35

  36. 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 36

  37. New York State MedicaidPrior Authorization Programs Questions and Discussion 37