On February 21, NYRx, the New York State Medicaid Pharmacy Benefit Program, held its monthly pharmacy sector meeting. On the agenda were the following:  

1. AIDS Institute – HCV (hepatitis C virus) drugs & test to treat model. 
   1. DOH (Department of Health) asked the following of pharmacies: 
      1. Does your pharmacy stock hepatitis C medications? How long does it take to get in stock? 
      2. How can we get medications in the client's hands more quickly? 
      3. How can providers build collaborations with their local pharmacies to ensure timely access to hepatitis C medications? 
      4. How have you worked with hepatitis C providers in your community? 
      5. Feedback can be shared with Colleen Flanigan (colleen.flanigan@health.ny.gov) 

1. OMIG (Office of the Medicaid Inspector General) Pharmacy Audit Protocols. 
   1. OMIG utilizes a stakeholder process for updated regulations that includes feedback from DOH and professional associations. OMIG reviews and considers all comments that are submitted before issuing a revised protocol set.  
   2. Bill Schwarz with OMIG added that updated protocols are in development. Feedback may be shared at information@omig.ny.gov. 

1. Bureau of Medical Review – Incontinence Supplies. 
   1. Incontinence products claims have doubled since 2019 and require a valid diagnosis code that directly relates to incontinence for reimbursement. 
   2. Incontinence products info can be found in the DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics and Supplies) Procedure Manual. 
   3. Starting in April, the DME (Durable Medical Equipment) Procedure Manual will be updated with a separate pharmacy manual. DMPOS Procedure Manual will contain everything that Managed Care Plans are still responsible for.  
   4. Questions: OHIPMedPA@health.ny.gov (1-800-342-3005) 

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

NYRx, the New York State Medicaid Pharmacy Benefit Program, announced an update to its Brand Less Than Generic program (BLTG). Advair HFA® and Advair Diskus® are subject to the NYRx BLTG. In December 2023, due to market availability issues, NYRx temporarily allowed for generic Advair HFA® and Diskus® to adjudicate without prior authorization (PA) if the brand product was not available from the pharmacy’s wholesaler. The manufacturer has confirmed that Advair HFA and Diskus supply issues have resolved, and pharmacies will be able to obtain the supply needed for their NYRx members. Effective February 28, fluticasone/salmeterol HFA and Diskus (generic Advair) will once again require PA.

Also in New York, 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. 

 Also in New York, Sen. Jeremy Cooney (D) introduced a bill, S8545, that authorizes registered pharmacy technicians to administer the same immunizations as licensed pharmacists under direct supervision of such licensed pharmacist. NACDS, in conjunction with the Community Pharmacy Association of New York State, will continue to support the bill and encourage passage this session. 

Finally in New York, Gov. Kathy Hochul (D) signed S8096, a bill that relates to the effective date of the self-administered hormonal contraceptive prescribing authority for pharmacists. The new law changes the effective date of the 2023 law from eighteen months from enactment to January 1, 2024.  

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

On February 6, the Department of Financial Services posted updated, proposed regulations on PBMs. NACDS is reviewing the regulations and will get analysis out to members as soon as possible.  

Also in New York, NACDS will be participating in the Community Pharmacy Association of New York State lobby day on February 13 in Albany. On the agenda is advocacy for test and treat legislation, budget sections that impact Medicaid reporting, inspector general audit rules and other scope expansion.  

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

NYRx, the New York Medicaid Prescription Drug Program, made the following changes to the preferred drug list. Effective February 7, the following changes will be made to the Dispense Brand Name Drug When Less Expensive Than the Generic Program: 

1. Alphagan P® 0.1%, Forteo® and Votrient® will be ADDED to the program.
2. Flovent® HFA and Pennsaid® pump will be REMOVED from the program. Note: Pennsaid® pump has been discontinued by the manufacturer.
3. Diclofenac 2% topical solution will remain in non-preferred status on the NYRx Preferred Drug List. Prescribers should transition their patients to an alternative preferred product or obtain a prior authorization for the diclofenac 2% solution. 

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: 

1. Do not require "Dispense as Written" (DAW) or "Brand Medically Necessary" on the prescription.
2. Have a generic copayment.
3. Are paid at the Brand Name Drug reimbursement rate or usual and customary price, whichever is lower (SMAC/FUL are not applied).
4. Do not require a new prescription if the drug is removed from this program. 

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

NYRx, the Medicaid Pharmacy Benefit Program, updated the preferred drug list, impacting Albuterol HFA formulations. The following are preferred in the NYRx Preferred Drug Program: 

• albuterol HFA – generic ProAir® HFA (8.5 grams) 
• albuterol HFA – generic Proventil® HFA (6.7 grams) 
• Proventil® HFA 
• Ventolin® HFA BLTG (Ventolin® HFA is subject to the Brand-Less-Than-Generic Program. The generic formulation of Ventolin® HFA, albuterol HFA (18 grams), is non-preferred and will require prior authorization.) 

Effective February 7, NYRx will make the following changes to the Brand Name Drug When Less Expensive Than the Generic Program: 

• Alphagan P® 0.1%, Forteo® and Votrient® will be ADDED to the program. 
• Flovent® HFA and Pennsaid® pump will be REMOVED from the program. 

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

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’ Mike Sargent at 207-272-6435.

NYRx, the New York Medicaid Pharmacy Benefit Program, issued this update regarding the NYRx BLTG (Brand Less Than Generic) Program for Flovent® and Advair®.  

Also in New York, the Board of Pharmacy sent out two updates on January 2:  

• The online Discontinuance Form discussed at the regular November meeting is now accessible to the public. Directions and further information regarding the online Discontinuance Form can be found online.  
• The Board has finalized and posted the new Drug Retail Price list online.  

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

NYRx, the State Department of Health Medicaid Pharmacy Benefit Program, released updates to the NYRx Prior Authorization Programs and updated preferred drug list, changes were effective December 14. 

The State Department of Health also released a reminder regarding pharmacy providers and members out-of-pocket costs. This communication was sent to all pharmacies to remind them of their responsibility for continued enrollment, to adhere to the policies and procedures of the Medicaid Program. Specifically, it is inappropriate to allow an eligible member to pay out-of-pocket for services that are covered by NY Medicaid (NYRx) beyond copay. Please be advised that out-of-pocket expenses are only reimbursable by Medicaid for Medicaid covered services when one of these three situations applies:  

• Reimbursement can be made for both participating and non-participating Medicaid Providers during the three-month retro period up until they submit the application. 
• Reimbursement can be made for only Medicaid participating Providers from the date the application is submitted up until they receive the Common Benefit Identification Card (CBIC). 
• Reimbursement can be made for both participating and non-participating Medicaid Providers due to agency error or delay. 

If there is an eligibility issue that is corrected in a timely manner, pharmacists should resubmit the claim when the issue is resolved and reimburse the member directly if the member paid out of pocket. There is support available to pharmacists to assist with claim issues. Questions regarding this communication may be directed to NYRx@health.ny.gov. 

On December 12, A6779, a bill NACDS and the Community Pharmacy Association of New York (CPANY) had been supporting to expand the 2022 law allowing pharmacists to administer long-acting injectables, was sent to the Governor's desk by the legislature. Gov. Kathy Hochul (D) has until December 22 to act on the legislation. 

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

Effective November 29, the New York Department of Health issued updated guidance regarding dispensing of COVID-19 over-the-counter tests at the pharmacy.

NYRx, the New York State Medicaid Pharmacy Benefit Program, sent a release to pharmacy providers on December 6^th. The program continues to field questions and concerns from residency program coordinators about pharmacies not able to submit claims to NYRx written by their interns and residents. NYRx asked the following shared regarding submission of claims:

1. Provider Manuals (emedny.org)
2. Provider Manuals – Pharmacy Manual (emedny.org)
3. pdf (emedny.org)
4. NYRx, the Medicaid Pharmacy Program | Education & Outreach (fhsc.com)

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