On January 16, Gov. Kathy Hochul (D) announced her current year budget proposal. The impactful sections are below:   

  1. Streamline Medicaid Drug Cap – to streamline and remove prior triggers to enable the state to get manufacturer rebates more quickly 
  2. Discontinue Prescriber Prevails – to eliminate prescriber prevails in Medicaid where clinical standards for approval are not met 
  3. Pharmacy Enhancements and Integration Specialty Drug Management – to create new benchmarks for physician administered drug reimbursement similar to pharmacy reimbursement under Medicaid Fee-for-Service (FFS); part of the goal is to bring drugs that do not have a NADAC up to WAC instead of current WAC-3%. Also, it includes requirement for all Medicaid enrolled pharmacies to submit annual cost reports in a form requested by the state Department of Health (DOH).  
  4. Reduce Coverage for Over-The-Counter (OTC) Pharmaceuticals – to enable DOH to modify the list of OTCs covered in the Medicaid program  

 

Also in New York, NYRx, the New York Medicaid Pharmacy Benefit Program, held its regular industry call on January 17. Updates are below; however, two other conversations occurred during the call, including Pharmacy Cost Reporting proposed in the budget and Inspector General (OMIG) audit protocols regularly updated to reflect Medicaid FFS pharmacy policies, e.g., change in signature on deliveries requirement. OMIG will be joining the February Pharmacy Sector call. 

  1. Covid-19 Oral Antivirals: DOH discussed new guidance related to billing for antivirals (Paxlovid™ and Lagevrio™). 
  2. Covid-19 Vaccine Billing for non-VFC (Vaccines for Children) Pharmacies: DOH discussed guidance for billing non VFC and admin code to use for VFC and non-VFC which can be found here. 
  3. 1115 Waiver: 3-year waiver approved totaling $7.5 billion through March 31, 2027.  

NYRx also revised its preferred drug list, effective January 18.  

For more information, please contact NACDS’ Ben Pearlman at 617-515-2603.