NYRx Medicaid Pharmacy Program: Post-Transition Roles & Responsibilities

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This document is intended to provide a high-level overview of the roles and responsibilities for the Office of Health Insurance Programs (OHIP), NYRx Medicaid Pharmacy Program Contractors, and contracted managed care plan (MCP) partners. This document is not intended to give an exhaustive list but to represent the most critical functions that each respective entity is responsible for pertaining to the Medicaid Pharmacy Program.

DOH
(OHIP)		 FFS Pharmacy Contractors
(CMA, DiRAD, GDIT/Kepro, Prime Therapeutics State Government Solutions LLC (formerly Magellan Rx), Maximus, SUNY)		 Managed Care Plans
(MCPs)
DOH will be responsible for activities including but not limited to the following:
  • Program Administration: Providing for the administration of the pharmacy benefit including but not limited to claims processing, customer service, formulary and clinical program management, and drug utilization review.
  • Financial Management: Oversight and management of pharmacy expenditures and rebates.
  • Contract Management: Oversight and monitoring of FFS pharmacy contractors, including review of performance/deliverables, approval of invoices, etc.
  • Drug Utilization Review (DUR) Program & Board Oversight: Oversight and administration of the DUR program (Pro-DUR & Retro-DUR) and Board activities. Collaboration with the Managed Care Plans (MCPs) to ensure consistency and alignment with plan administered disease and medication management programs.
  • Policy Development & Maintenance: Developing, implementing, and maintaining Medicaid pharmacy policy, including but not limited to drug coverage and clinical criteria. Interfacing with contracted plan partners regarding policies, to ensure consistency.
  • Rebate Administration: Conduct negotiations, evaluate rebate offers, report and monitor rebate invoicing activities and collections.
  • Pharmacy Enrollment & Reimbursement: Establishing & maintaining the FFS pharmacy network and reimbursement methodologies, consistent with applicable state and federal requirements.
  • Data Access/Sharing: Providing contracted plan partners access to data for the purposes of coordinating care.
  • Fraud, Waste and Abuse in collaboration with MCPs and other State Agencies, e.g., the Office of the Medicaid Inspector General (OMIG).
 Established FFS Pharmacy Contractors will be responsible for the continuation of activities including but not limited to the following:
  • Program Administration:
    • Claims processing & Systems Administration (GDIT)
    • Automated Prior Authorization (GDIT/Kepro)
    • Call Center Services/Customer Service
      • Pharmacy Help Desk (GDIT)
      • Prior Authorization (Prime Therapeutics State Government Solutions LLC)
      • Enrollment & Eligibility (Maximus)
    • Enteral Product Prior Authorization (DiRAD)
    • Drug Utilization Review (DUR)
      • Prospective DUR: (GDIT)
      • Retro DUR: (GDIT/Kepro, SUNY)
    • Rebate Administration: (Prime Therapeutics State Government Solutions LLC)
    • Provider Enrollment: (GDIT)
    • Data Access/Sharing: (GDIT, CMA)
 Managed Care Plans will be responsible for activities including but not limited to the following:
  • Care Coordination: Overseeing and maintaining all activities necessary for enrolled NYS Medicaid beneficiary care coordination and related activities, consistent with contractual obligations
  • Clinical Management: Providing oversight and management of all the clinical aspects of pharmacy adherence, including providing disease and medication management to optimize health outcomes and collaboration with DOH to ensure consistency with DUR reports and recommendations.
  • Claim Payment: Processing and payment of certain pharmacy services billed on medical and institutional claims and continued submission of these claim encounters to the State.
  • Drug Utilization Review (DUR) Program & Board Oversight: Participating in collaborative DUR and other DOH pharmacy committee meetings.
  • Fraud, Waste and Abuse as defined under the Managed Care Model Contract in collaboration with State Agencies.