NYS Department of Health Medicaid Update
December 2011
Fee-for-Service Pharmacy Reform
Prior Authorization for Atypical Antipsychotics
The enacted 2011-2012 New York State (NYS) Executive Budget included
several significant changes to the Medicaid fee-for-service (FFS)
pharmacy benefit. One of those changes was to eliminate the exemption
from prior authorization requirements for drugs in the following
therapeutic classes: atypical anti-psychotics, anti-depressants,
anti-rejection drugs used for the treatment of organ and tissue
transplants and anti-retroviral drugs used in the treatment of HIVIAIDS.
As previously announced, the Department delayed implementation of this
initiative until systems were in place to support the grandfathering of
patients stabilized on non-preferred atypical anti-psychotics. Those
systems will be in place in late December 2011.
Effective December 29, 2011, prior authorization will be required for
atypical anti-psychotics identified as nonpreferred on the Medicaid
Preferred Drug List.
System editing will be performed at the point-of-service that will allow
claims to reimburse without prior authorization when clinical criteria
are met such as when a beneficiary has been stabilized on a
non-preferred product. When clinical criteria are not met, pharmacy
providers will receive an edit message instructing them to notify the
prescriber to change the prescription to a preferred drug, if
appropriate, or to obtain prior authorization through the clinical call
center at (877) 309-9493 for the non-preferred drug.
=====================
New Changes to the Fee-for-Service Pharmacy Prior Authorization Process
On December 29, 2011, the Department will begin phasing in changes to
the Medicaid pharmacy fee-for-service (FFS) prior authorization process.
System editing will be performed at the point-of-sale to allow claims to
pay without prior authorization when clinical criteria are met, such as
when a beneficiary has been stabilized on an atypical anti-psychotic or
when a claim meets clinical rules established by the Medicaid Drug
Utilization Review Board or Pharmacy & Therapeutics Committee.
Effective December 29, 2011:
All FFS pharmacy claims will be subject to clinical rules at the
point-of-sale.
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 through the clinical call
center at (877) 309-9493.
Prescribers must obtain prior authorization through the clinical call
center for claims that do not meet clinical criteria.
What does this mean for me?
Pharmacy providers will no longer have to validate prior authorizations.
Prescribers will only have to obtain prior authorization when clinical
criteria are not met.
Prior authorization numbers will be generated systematically and will no
longer need to be written on a prescription or submitted on a claim.
http://www.health.ny.gov/health_care/medicaid/program/update/2011/dec201
1mu.pdf