Scope of Benefits

Pharmacy Benefits Affected by Transition from Managed Care

The FFS NY Medicaid Pharmacy Program will not change the scope (e.g. copayments, covered drugs, etc.) of the existing Medicaid Pharmacy benefit, including the following:

Medicaid Pharmacy List of Reimbursable Drugs

Lists drugs covered outpatient prescription and over-the-counter (OTC) drugs.

Pharmacy Procedures and Supply Codes

Lists pharmacist-administered vaccines as well as supplies, such as enteral and parenteral nutrition, family planning, and medical/surgical supplies.

Pharmacy Benefits Charts

These charts provide a snapshot of what is changing and what is not in relation to pharmacy services in MC and FFS delivery systems. They list the current state (pre-transition) and future state (post-transition). Additionally, the charts provide an inventory of the NYS Medicaid's outpatient pharmacy benefit, whether the benefit is subject to the transition, and whether the managed care plans should continue to make the benefit available when provided by a non-pharmacy provider.

Preferred Drug Program (PDP)

This program promotes the use of less expensive, equally effective prescription drugs when medically appropriate. All drugs currently covered by Medicaid remain available under the PDP and the determination of preferred and non-preferred drugs does not prohibit a prescriber from obtaining any of the medications covered under Medicaid. The Drug Utilization Review Board (DURB) reviews drug classes and makes recommendations to the Commissioner of Health regarding the selection of preferred and non-preferred drugs within certain drug classes.

Brand Less Than Generic Program (BLTG)

This program is a cost containment initiative which promotes the use of certain multi-source brand name drugs when the cost of the brand name drug is less expensive to the State, than the generic equivalent.

Clinical Drug Review Program (CDRP)

This program is aimed at ensuring specific drugs are utilized in a medically appropriate manner. Under the CDRP, certain drugs require prior authorization because there may be specific safety issues, public health concerns, the potential for fraud and abuse or the potential for significant overuse and misuse.

Drug Utilization Review (DUR) Program

This program helps to ensure that prescriptions for outpatient drugs are appropriate, medically necessary, and not likely to result in adverse medical consequences. DUR programs use professional medical protocols and computer technology and data processing to assist in the management of data regarding the prescribing of medicines and the dispensing of prescriptions over periods of time.

Mandatory Generic Drug Program (MGDP)

This program requires prior authorization for brand-name prescriptions with an A-rated generic equivalent. State law excludes Medicaid coverage of brand name drugs that have a Federal Food and Drug Administration (FDA) approved A-rated generic equivalent, unless a prior authorization is obtained. Drugs subject to the PDP and/or the BLTG Program are not subject to the Mandatory Generic Program.

Dose Optimization Program

This program can reduce prescription costs by reducing the number of pills a patient needs to take each day. The Department has identified the drugs that are included in this program, the majority of which have FDA approval for once-a-day dosing, have multiple strengths available in correlating increments at similar costs and are currently being utilized above the recommended dosing frequency.

Preferred Diabetic Supply Program (PDSP)

The NYS Medicaid Program participates in a Preferred Diabetic Supply Program (PDSP) to provide NYS Medicaid enrollees access to quality glucose meters and test strips, while at the same time reducing overall program costs.

Medicaid Pharmacy Transition to FFS: Post-Transition Roles & Responsibilities

Physician administered (J-Code) drugs that are not listed on the Medicaid Pharmacy List of Reimbursable Drugs and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) as listed in sections 4.4, 4.5, 4.6, and 4.7 of the Durable Medical Equipment, prosthetics and Supplies Manual are not subject to the transition.