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.

On March 17, Gov. Kathy Hochul (D) announced the launch of DFS Connect, a new digital program launched by the Department of Financial Services (DFS) that will centralize the Department’s interactions with both regulated entities and consumers and ensure better service to businesses and consumers. Building on the state’s actions to protect New Yorkers from rising drug costs, the initial functions launched today on DFS Connect provide a streamlined and transparent way to file complaints for prescription drug prices that increase more than 50 percent over the course of a year and PBMs. Additionally, individuals can file complaints via mail or by calling the DFS Hotline.

Also in New York, the Office of Health Insurance Programs of the State Department of Health has approved the release of the January 2025 Medicaid Update. Relevant sections are below:

Pharmacy

• NYRx Medicaid Pharmacy Prior Authorization Programs Update
• Notice for Upcoming Over-the-Counter Coverage Changes
• NYRx Pharmacy Drug Coverage: Claims Processing Enhancements and Reminders

 All Providers

• eMedNY Provider Training Videos Available
• Recipient Restriction Program Restriction Edits Restored
• New York State Medicaid Evidence Based Benefit Review Advisory Committee Meeting on April 10, 2025

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

The state’s Department of Health provided notice to pharmacies that NYRx, the state Medicaid pharmacy benefit program, had changes to over the counter (OTC) drugs.

Effective April 1, NYRx will remove the following products from the List of Reimbursable Drugs:

• Cough and Cold Products: Oxymetazoline, Phenylephrine
• Gastrointestinal Products: Simethicone
• Anti-hypoglycemics: Glucose Tablets
• Dermatologicals: Neomycin, Bacitracin
• Multivitamins: For members aged 21 years and up

Impact on Providers and Patients

• Transition to Alternative Therapies: Providers are encouraged to discuss these changes with their patients. Alternative treatment options are available for medically necessary use. For example, alternatives to oxymetazoline or phenylephrine may include other decongestants or nasal corticosteroids that offer more effective management of nasal congestion.
• Patient Education: NYRx has notified members of these changes. Additionally, provider education to patients about these formulary changes is helpful and provide safer and more effective alternatives. Ensuring that patients understand the rationale behind these changes and the benefits of alternative therapies is essential for a smooth transition.
• Adjusting Prescribing Practices: Given these changes, providers may need to modify their prescribing practices. Staying informed about which medications remain covered and considering the most appropriate therapies for patients’ needs will be crucial. The New York Medicaid list of reimbursable drugs is available online.

NYRx is committed to continuously monitoring medication utilization and effectiveness to ensure that the OTC formulary remains aligned with evidence-based practices.

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

The New York Department of Health held its monthly pharmacy industry call for NYRx, the state Medicaid pharmacy benefit program on February 19, 2025. The agenda included (1) DME supplies, processing of incontinence supplies, as this is the highest category of waste, fraud and abuse in the program today; (2) enhancements to the internal system for prior authorizations which allow the state to override and amend as needed; and (3) unenrolled providers are rejected by EMEDNY, if there are any concerns, make sure your pharmacy is enrolled when activating.  The next monthly meeting will be March 19, 2025, at 1pm.

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

On January 21, Gov. Kathy Hochul (D) released her budget proposal. The budget includes the following outside sections relevant to pharmacies:  

• Pharmacist Vaccinations: Would codify PREP Act authorization for pharmacists to administer a COVID-19 vaccine to children ages 2 years and older. 

• Pharmacist Cessation: Would authorize a pharmacist to prescribe and order medications to treat nicotine dependence approved by the US Food and Drug Administration for smoking cessation. 

• Pharmacy Tech Vaccinations: Would codify PREP Act authorization for registered pharmacy technicians to administer all vaccines that pharmacists may administer under the supervision of a pharmacist, if they meet training requirements, etc.  

• Medical Assistant Vaccinations: Would authorize a medical assistant under the supervision of a physician or a physician’s assistant (PA) to administer vaccinations. 

• Controlled Substances: Proposes to align the state’s controlled substance schedules with the US Drug Enforcement Administration.  

• Medication Abortion Labels: Would require pharmacies, at the request of the prescriber, to list only the facility name, not the prescriber’s name on prescription pill bottles for mifepristone, misoprostol and other medication abortion drugs.  

• Prescriber Prevails: Proposes to eliminate prescriber prevails in Medicaid. The program would have to consider additional information related to coverage, but the program’s determination would be final. 

• Medicaid Global Spending Cap: Extends the global spending cap one year through 2026-2027. 

NACDS will continue to monitor the budget process in the state and advocate for policy priorities.  

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

Gov. Kathy Hochul (D) signed A8880A/A1010B, an Act Prohibiting Label Restrictions of Over-the-Counter (OTC) Drugs. The bill makes it illegal to knowingly alter, mutilate, destroy, obstruct or remove by means of a price sticker or otherwise the whole or any part of the label, including where applicable the expiration date displayed thereon, of any OTC drug or cosmetic.

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

On November 20, the State Department of Financial Services made final PBM market conduct regulations. The regulations will become effective on November 27, 2024. The market conduct regulations require the following:

• Allow Home Delivery. Prohibit PBMs from barring any in-network pharmacies from providing mail order or delivery services, which will increase patients’ access to home delivery from their community pharmacy;
• List Pharmacy Directories. Increase transparency to consumers and employers by requiring PBMs to list formularies and pharmacy directories online, and prohibiting PBMs from punishing a consumer who relies on said information;
• Address Consumer Inquiries. Require PBMs to post a telephone number and email address for consumers to direct their questions to, and PBMs must respond in a reasonable amount of time;
• Prohibit Steering. Prohibit anti-competitive practices that steer consumers away from their community pharmacy to larger pharmacies affiliated with the PBM;
• Treat Pharmacies Fairly. Prohibit PBMs from unfairly passing losses onto pharmacies when the PBM mistakenly approved dispensing a drug and then seeks to retroactively deny reimbursement to the pharmacy;
• Allow Electronic Submissions. Reduce administrative burdens and costs on small pharmacies by allowing them to submit information to and receive information from PBMs electronically; and
• Apply Same Standards. Prevent the abuse of audits against small pharmacies who are not affiliated with a PBM by requiring PBMs to apply the same audit standards across all in-network pharmacies.

Also in New York, on November 20, NYRx, the Medicaid Pharmacy Benefit Program, held its monthly pharmacy industry call. Two items on the agenda were (1) Non-Individual Specific Prescription for Self-Administered Hormonal Contraceptives with Pharmacy Dispensing Protocol

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

On October 25, 2024, the State Department of Health updated its “Pharmacists as Immunizers” Fact Sheet. The fact sheet includes updated billing codes, reminder that Medicaid is the payor of last resort and highlighting the change that immunizations of children ages three to 17 years will no longer be authorized as of December 31, 2024. 

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

NYRx released an updated Pharmacy Vaccine Billing Guidance, with new fees effective October 24.

Also in New York, on October 16, the State Department of Health hosted its monthly NYRx Pharmacy call. The agenda items included:

1. OMIG Restricted Recipient Program: Requirements for primary care providers and pharmacies for patients in this program including new edits taking effect in November 2024 and February 2025, and billing and referral instructions.
2. Reimbursement Changes under NYRx: Effective October 1, paying WAC for brand drugs that lack a NADAC (was WAC-3%)
3. III. New Guidance Allowing 90-Day Prescriptions and 90-Day Prescribing under NYRx
4. NYRx Coverage of OTC Progesterone-Only Contraception: With Opill available, NYRx reminder that they will only cover it for those with Medicaid if they obtain it from a pharmacist who is authorized to dispensing hormonal contraception per new law/ standing order and following patient questionnaire/counseling etc. or with a fiscal order from their prescriber.
5. NYRx Compound Policy
6. Prior Authorizations: Slides include clarification on NYRx prior authorization policies per a request for guidance.

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