Michael Silber, Author at In The States

New York

On April 1, the state’s Department of Health announced that beginning this summer, NYRx, the Medicaid Pharmacy Program, will accept electronic prior authorization (ePA) requests via CoverMyMeds® in addition to phone and fax requests.

CoverMyMeds is a tool designed to simplify the prior authorization process by prompting prescribers to answer required clinical questions that can offer real-time approvals if clinical criteria are met. Prescribers can electronically submit prior authorization requests, upload supporting documents and track request status in real time. Additionally, pharmacy providers who utilize CoverMyMeds will have the opportunity to initiate medication ePA requests on behalf of the member for completion by the prescriber. CoverMyMeds will direct the case to the prescriber’s queue and prompt them to complete and submit the ePA to NYRx. Further communications, including effective dates, resources, and educational events, will be coming soon.

What Pharmacy Providers and Prescribers Need to Do

Read the Quick Guide to CoverMyMeds Prior Authorization Requests to learn more about CoverMyMeds.

Visit the CoverMyMeds Log In page to create an account, complete your profile and become familiar with the application.

Also in New York, the NYRx Education & Outreach (E&O) team would like to invite interested parties to live training webinars, held weekly on Mondays, Wednesdays, and Fridays from 12:00 noon – 1:00 pm Eastern, excluding holidays. The live webinars focus on different areas of NYRx, the Medicaid Pharmacy Program. Registration is required to join. To attend an online seminar, starting April 2025, please click on the links provided below, or you may visit the NYRx Education & Outreach website to register.

At each presentation’s end, there will be time for a live question/answer session. Please share this information with others in your organization that may be interested or would find this online seminar helpful.

NYRx Pharmacy Webinar: *NEW* A customized online seminar directed toward pharmacies, pharmacists and pharmacy staff who care for NYS Medicaid members.

It is held weekly on Wednesday, from 12:00 noon – 1:00 pm Eastern. To register:

April 9: click here

April 16: click here

April 23: click here

April 30: click here

Please send an email to NYRxEO@primetherapeutics.com for any questions or if you and your organization would like to schedule a webinar specific for your office staff or network. The NYRx E&O is happy to accommodate your schedule. Want to learn more about NYRx E&O? Visit our website: NYRx Education and Outreach website.

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

Michael Silber2025-04-03T14:28:39-04:00April 3, 2025|New York|

Oregon

The Board of Pharmacy posted the April 9-11 Board Meeting agenda and meeting materials. Please note that on April 9, the board will meet in Executive Session immediately after recusal announcements and anticipates resuming Open Session around 4:30 pm. Also, note that on April 10, the board will meet in Executive Session after roll call and anticipates resuming Open Session between 1:00 pm-2:00 pm. Finally, the board will meet in Open Session on April 11. Please see the meeting agenda for additional information. 

Also in Oregon, State Plan Amendment (SPA) 24-0019 to increase professional dispensing fees for fee-for-service pharmacies, with fees ranging from $9.99 to $16.87 per prescription, depending on volume, and $20.86 for 340B covered entities is pending with the Centers for Medicare and Medicaid. As submitted by the Oregon Health Authority, this SPA proposes to update Oregon’s professional dispensing fees (PDF) to $16.87 for pharmacies with a prescription volume of less than 40,000 claims per year, $11.93 for pharmacies with a prescription volume of 40,000 to 79,999 claims per year, and $9.99 for pharmacies with a prescription volume of 80,000 or more.

The Prescription Drug Affordability Board posted its April 2025 issue of The Quarterly. Highlights of this issue include the following. Past issues are available online.

PDAB would love to hear from Oregonians, Page 1

PDAB selects subset list for affordability reviews, Page 2

PDAB member profile: Dan Kennedy, Page 5

News you can use, Page 6

Senate Health Care Committee advances Senate Bill 289, Page 7

2025 board meeting calendar, Page 8

Also in Oregon, the Prescription Drug Affordability Board posted it is agenda for the April 16 meeting. Register here in advance.

Also in Oregon, the Oregon Health Authority Health Systems Division: Medical Assistance Programs adopted this temporary rule, OAR 410-122-0186, to amend Medicaid fee-for-service durable medical equipment, prosthetics, orthotics and supplies to comply with the recently approved state plan amendment (SPA), effective October 1, 2024.

Finally in Oregon, the Division of Financial Regulation recently announced the following permanent rulemaking: ID 2-2025: Prescription Drug Price Transparency program updates

Rules: 836-200-0500, 836-200-0505, 836-200-0510, 836-200-0515, 836-200-0520, 836-200-0525, 836-200-0530, 836-200-0531, 836-200-0532, 836-200-0535, 836-200-0540, 836-200-0545, 836-200-0550, 836-200-0555, 836-200-0560.

Rules Summary: Adds a definition for “dosage;” combines the definitions for “inaccurate information” and “incomplete information;” adds clarification about what is not included in the definition of “new prescription drug;” removes dosage guidance from the definition of “one-month supply;” adds clarification to the definition of “reporting manufacturer; removes outdated timelines; sets timeline for reporting manufacturers to create an online account with the department; requires reporting manufacturers to provide the department with at least one contact person, with valid contact information, that is an employee who manages access to the account and receipt of trade secret determinations; updates the threshold for reporting new prescription drugs to reflect current specifications in Medicare Part D; provides a definition for the “date of introduction;” clarifies “good faith” language; clarifies requirements of manufacturer reporting including: drug strength, package size, and the date the drug was first approved; the description of the marketing used in the drug’s introduction; and potential factors used to establish the price of the new drug; and more. 

Filed: March 26, 2025

Effective: April 1, 2025

For more information, contact NACDS’ Sandra Guckian at 703-774-4801.

Michael Silber2025-04-03T14:27:41-04:00April 3, 2025|Oregon|

Rhode Island

Medicaid posted its April 2025 Provider Update. Please note the “Pharmacy Spotlight” with information about the Medicaid Fee-for-Service program’s Stand Along Vaccine Counseling project in Spring 2025. This project allows pharmacies to be reimbursed for vaccine counseling services using the Service Billing (SI) and Service Reversals (S2) Transactions on the NCPDP transaction standard. See the update for additional details. All previous provider updates may be found online.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

Michael Silber2025-04-03T14:26:50-04:00April 3, 2025|Rhode Island|

South Carolina

NACDS attended in the SC Senate Labor, Commerce, and Industry Committee’s presentations on PBMs and the Future of Pharmacy. The session featured insights from several stakeholders, including the SC Pharmacy Association; Eunice Medina, Director of the SC Department of Health, and Human Services; the Cicero Institute; and the SC Alliance of Health Plans.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

Michael Silber2025-04-03T14:26:17-04:00April 3, 2025|South Carolina|

Tennessee

The Department of Health is confirming the state’s first measles case in 2025 in a Middle Tennessee resident. The likely source of the infection is being investigated. Subsequently, the Department of Health confirmed three additional cases of measles in Middle Tennessee, which is also being investigated by public health officials.

Also in Tennessee, the Department of Commerce & Insurance added a new PBM Compliance Pharmacist position to serve as a pharmacy consultant and professional resource to the PBM Compliance Section. The position will be responsible for enforcement of current statutes and rules related to PBMs as well as assisting with compliance audits of PBMs, assisting with PBM complaint analysis and investigation and analysis of PBM Annual Reports.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

Michael Silber2025-04-03T14:25:46-04:00April 3, 2025|Tennessee|

Texas

Bills supported by all pharmacy groups are beginning to advance in the Senate.

SB 493 prohibits “gag clauses” in contracts that prevent pharmacies from telling patients when the cash price for a drug is lower than the price under their insurance plan. SB 493 addresses contractual provisions between some health insurers, pharmacy benefit managers and pharmacies that prohibit pharmacists from freely informing patients if paying out-of-pocket (cash price) for the prescription may be cheaper than the insured’s copay.

SB 1122 builds upon the landmark US Supreme Court Rutledge decision and PBM reforms passed in recent years, HB 1919 and HB 1763, by extending the applicability of patient and pharmacy protections already in law to all PBM activity in the state, regardless of the health plan types. It further codifies the February 2025, Texas Attorney General Ken Paxton opinion letter KP-0480, which asserts that Texas has the authority to regulate PBM practices impacting its residents and local pharmacies, even when ERISA-governed plans are involved.

SB 1236 amends current law relating to the relationship between pharmacists or pharmacies and health benefit plan issuers or pharmacy benefit managers. SB 1236 would amend Chapter 1369, Insurance Code, to provide reasonable contract protections for pharmacies and pharmacists in their relationships with PBMs. It would also amend existing statutes to clarify language regarding PBM audits and provide transparency in the applicability of Texas laws to contracts and benefit enrollees. This bill was heard in the Senate Health and Human Services Committee on April 1.

Also in Texas, another priority bill we are trying to advance includes HB 4533 by Rep. Tom Oliverson, MD, (R), legislation that would establish the fee-for-service reimbursement as the rate floor for Medicaid managed care organization claims.

Also in Texas, all pharmacy groups collaborated on making our united voices heard on our priority legislative issues at the March 26 Pharmacy Day at the Capitol. More than 400 pharmacists, interns and pharmacy students participated in 150 scheduled meetings, urging lawmakers to pass legislation to help save neighborhood pharmacies and the health of their patients.

Finally in Texas, Gov. Greg Abbott (R) launched a Department of State Health Services (DSHS) online interactive map identifying where Texans can acquire life-saving naloxone (NARCAN) to prevent fentanyl poisonings. This tool is part of the statewide “One Pill Kills” campaign.

For more information, contact NACDS’ Mary Staples at 817-442-1155.

Michael Silber2025-04-03T14:25:02-04:00April 3, 2025|Texas|

Virginia

After passing the General Assembly with overwhelming support, Gov. Glenn Youngkin (R) gutted the Medicaid Managed Care Single PBM bills (HB 2610 and SB 875) and sent them back to the General Assembly, leaving only language to study the issue. On April 2, the General Assembly held steadfast, rejecting the Governor’s version, and voted to send the original bills as they passed the Legislature back to the Governor. Gov. Youngkin now has thirty days to sign or veto the measures. With the 2025 session at an end, his action will be the final word on the bills.

For more information, contact NACDS’ Jill McCormack at 717-592-8977.

Michael Silber2025-04-03T14:24:27-04:00April 3, 2025|Virginia|

Washington

NACDS submitted comments for the Sunrise Review process of pharmacy practice regulations to the Department of Health, recommending adopting a standard of care model that would better utilize pharmacists’ clinical expertise in promoting healthcare access for its residents through community pharmacies.

For more information, contact NACDS’ Mary Staples at 817-442-1155.

Michael Silber2025-04-03T14:23:51-04:00April 3, 2025|Washington|

West Virginia

A bill granting pharmacists broad prescriptive authority passed the Senate overwhelmingly and is now in the House Health and Human Resources Committee for consideration. SB 526 allows pharmacists to prescribe any appropriate therapy to treat a condition diagnosed by a CLIA-waived test.

For more information, contact NACDS’ Jill McCormack at 717-592-8977.

Michael Silber2025-04-03T14:23:17-04:00April 3, 2025|West Virginia|

About Michael Silber