NYRx, the State Medicaid Pharmacy Benefit Program, announced effective June 12, the following changes were made to the Dispense Brand Name Drug When Less Expensive Than the Generic Program: 

• Anoro Ellipta®, Motegrity® and Promacta® tablets were be ADDED to the program. 

• Glumetza® and Xopenex HFA® were removed from the program. Glumetza® is being removed as it has been discontinued by the manufacturer. 

In conformance with State Education Law, a pharmacist shall dispense a less expensive, therapeutically equivalent drug containing the same active ingredients, dosage form and strength as the drug prescribed/ordered. This includes substituting the brand name drug when NYRx has determined it to be the less expensive alternative for the patient. Brand name drugs included in this program: 

• Do not require "Dispense as Written" (DAW) or "Brand Medically Necessary" on the prescription. 

• Have a generic copayment. 

• Are paid at the Brand Name Drug reimbursement rate or usual and customary price, whichever is lower (SMAC/FUL are not applied). 

• Do not require a new prescription if the drug is removed from this program. 

The NYRx Education & Outreach Call Center is available by phone at 1-833-967-7310 or by email at NYRxEO@primetherapeutics.com from 8:00 am to 5:00 pm Eastern, Monday through Friday, excluding holidays. 

The NYRx Education & Outreach team hosts virtual office hours every week for stakeholders to ask questions related to NYRx and care coordination. Visit the NYRx Education & Outreach website for more information. 

For more information, please contact NACDS’ Mike Sargent at 207-272-6435.

A678/S3236, legislation that allows pharmacy technicians to practice in any pharmacy under the supervision of a pharmacist, has been passed by both chambers. The bill now moves to the Governor for signing. NACDS and the Community Pharmacy Association of New York have advocated for this bill all session, having directly lobbied both chambers and the administration.  

Also in New York, the State Department of Health held its monthly pharmacy call to discuss NYRx, the New York state Medicaid pharmacy benefit program. The agenda included two items: a change in covered diabetic supplies (see below) and a reminder that electronic prior authorizations will start this summer through CoverMyMeds.  

• As a reminder, NYS Medicaid is the payor of last resort and providers are required to bill all applicable third-party payors before Medicaid. For additional information about the coordination of benefits, refer to NYRx Third Party Liability and Coordination of Benefits.  

• If a member cannot switch from a LifeScan product to a Preferred Diabetic Supply, the pharmacy can request a review of the claim for payment by NYRx by following the steps outlined below. Consideration will be made if there are formulary limitations with the primary payor and it is not possible to switch the member to a preferred product.  

• The pharmacy provider may fill out this form and submit it to eMedNY Claims Processing for review. Responses will be faxed back to the pharmacy within three business days. Providers may also call the eMedNY Call Center at 1-800-343-9000 to request a review of the claim.  

For more information, please contact NACDS’ Mike Sargent at 207-272-6435.

On May 5, NYRx issued a notice NYRx Helpful Hints for Pharmacies: Diabetic Testing Supplies.  

Diabetic Test Strips and Lancets: NYRx coverage of preferred blood glucose test strips and lancets for members with diabetes aligns with Medicare Coverage of Diabetes Supplies.  

Pharmacies must submit claims based on units per days' supply as follows:  

• Members who use insulin: Maximum 300 test strips and lancets per 90-day supply    

• Members who do not use insulin: Maximum 100 test strips and lancets per 90-day supply   

Continuous Glucose Monitors and Disposable Insulin Pumps: Continuous Glucose Monitors and Disposable Insulin Pumps should be billed at the pharmacy point-of-sale for the proper quantity and days' supply as outlined on the product label.  

What Pharmacies Need to Do: The pharmacy should become familiar with the NYRx Preferred Diabetic Supply Program. When submitting claims for preferred diabetic supplies do not request a PA (prior authorization) from the prescriber if the claim rejection states one of the following:  

• Maximum Quantity Exceeded  

• Early Fill Overuse  

• Recipient Ineligible on Service Date  

• Refill Number Exceeds Maximum  

• Therapeutic Duplication  

• Client Has Medicare Part D or Client Has Other Insurance  

• Coordination of Benefits Claim Processing  

• NYRx is always the payor of last resort and federal regulations require that all other available resources be used before NYRx considers payment.   

 The NYRx Education & Outreach Call Center is available by phone at 1-833-967-7310 or by email at NYRxEO@primetherapeutics.com from 8:00 am to 5:00 pm ET, Monday through Friday, excluding holidays. 

For more information, please contact NACDS’ Mike Sargent at 207-272-6435.

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’ Mike Sargent at 207-272-6435.

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’ Mike Sargent at 207-272-6435.

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’ Mike Sargent at 207-272-6435.

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’ Mike Sargent at 207-272-6435.

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’ Mike Sargent at 207-272-6435.

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’ Mike Sargent at 207-272-6435.