The State Department of Financial Services posted its proposed rulemaking for Pharmacy Benefit Managers regulation on May 24, 2023. The purpose is to establish rules for PBMs regarding assessments, license requirements, reporting and record keeping and to clarify definitions. Public comments are due 60 days from when this was published.

The NYRx Medicaid Pharmacy Benefit transition announced this week a 30-day countdown for transition fills. As you know, as of April 1, 2023, Medicaid members enrolled in mainstream Managed Care (MC) plans, Health and Recovery Plans (HARPs) and HIV-Special Needs (SNPs) began receiving their pharmacy benefits through NYRx, the Medicaid Pharmacy Program. 

To ensure a smooth transition for members, NYRx instituted a transition fill period from April 1, 2023, to June 30, 2023. During the transition period, members were provided a one-time transition fill for up to a 30-day supply of a drug that would normally require prior authorization (PA) under the NYRx Preferred Drug Program (PDP). The one-time transition fill does not mean that a PA will not be required for future fills. Beginning on July 1, 2023, all claims will be subject to NYRx pharmacy program criteria listed on the NYRx PDL.

PAs issued by Medicaid Managed Care plans prior to April 1, 2023 (that are active/valid after April 1, 2023) will continue to be honored by NYRx. This includes clinical PAs that may also require PA under NYRx. The state encourages members to continue to use the portal and call with any issues. The upcoming change of note is starting July 1, 2023; all claims will require a prior authorization via the IVR/Portal System (with some exceptions). 

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

On May 16, the State Department of Health held a monthly NYRx Medicaid Pharmacy Benefit transition call for pharmacies. The state encourages members to continue to use the portal and call with any issues. The upcoming change of note is starting July 1, 2023; all claims will require a prior authorization via the IVR/Portal System (with some exceptions).

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

On May 2, Gov. Kathy Hochul (D) signed A 1060: pharmacists administered contraceptives into law. 

On the May 1 weekly NYRx Medicaid Pharmacy Benefit transition call, the State Department of Health reminded pharmacies that for the billing process for immunizations, there are different codes to use when billing for multiple vaccines and administration in the same day. Please see the following guidance. 

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

On April 27, 2023, Governor Hochul announced an budget agreement with the legislature that held off all efforts to repeal the NYRx, the Medicaid prescription benefit carve out for fee-for-service. As of April 1, 2023, all Medicaid members enrolled in Mainstream Managed Care now receive their prescription drugs through the program. 

On April 24, 2023, NACDS participated in a pharmacy lobby day in Albany, in collaboration with the Community Pharmacy Association of New York and the Pharmacist State Society of New York. Members and pharmacists lobbied in support of S3467: CLIA-waived testing, S6337: expanding the Long Acting Injectables law, and for final signature of A 1060: pharmacists administered contraceptives.  

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

Beginning April 1, the State Department of Public Health will be transitioning all Medicaid members to NYRx, the Medicaid Pharmacy Program.  The Department will be having a call center available for pharmacies and Medicaid recipients.  Please call 1-800-343-9000 if you experience any claims issues. The hours of operation will be Monday through Friday 7:00 am to 10:00 pm and Saturday and Sunday 8:30 am to 5:30 pm, with extended hours to 8:00 pm on April 1. The NYRx program will also be hosting calls for pharmacies regarding implementation on April 3 at 11:00 am.   

The next monthly stakeholder call for NYRx will be held April 18 at 1:00 pm. This call will be a webinar about the pharmacy benefit transition. Members, providers and all interested stakeholders are welcome to attend. Registration information will be posted one week prior. 

The State Assembly and Senate have both passed bill A1060A, an act relating to the self-dispensing of hormonal contraceptives. The legislation will authorize licensed pharmacists to provide contraceptives pursuant to a non-patient specific order from a physician or nurse practitioner. The legislation once signed by the Governor will take effect in 180 days.

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

On March 21, NACDS joined the Pharmacists Society of the State of New York (PSSNY) in a rally in support of the Medicaid transition to fee-for-service. Beginning April 1, all Medicaid members enrolled in Mainstream Managed Care will receive their prescription drugs through NYRx, the Medicaid Pharmacy Program.

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

On March 21, 2023, NACDS will be joining the Pharmacists Society of the State of New York (PSSNY (Pharmacists Society of the State of New York)) in a rally in support of the Medicaid transition to fee-for-service. Beginning April 1, 2023, all Medicaid members enrolled in Mainstream Managed Care will receive their prescription drugs through NYRx, the Medicaid Pharmacy Program. The rally is to advocate to the legislature so no action would alter the planned transition.

On March 21 at 1:00 p.m., the New York State Department of Health will be holding its next online seminar for all stakeholders about the pharmacy benefit transition. Members, providers

and all interested stakeholders are welcome to attend regarding the transition.

The New York Deparment of Financial Services’ Pharmacy Benefits Bureau is requesting comments directly from pharmacies about the usefulness of PBM audits. Specifically, the requested comments are about whether and how the Department should exercise its authority about audits of pharmacies conducted by PBMs. New York Insurance Law §§ 2905-2906 empowers the Department to establish, by regulation, minimum standards for the issuance of a license to a PBM, including both prerequisites for the issuance of a license and requirements for maintenance of a license. Among the questions for pharmacies are: “In what way, if any, does an auditing PBM communicate its audit policies and procedures to your pharmacy?”, “What types of audits have you experienced in the past five (5) calendar years?”, “How many times per year for the past five (5) calendar years have PBM audits occurred for your pharmacy?”, “During the most recent audit conducted by a PBM for your pharmacy, was the purpose or subject of the audit identified prior to the audit occurring?”, “Was the same identified purpose or subject included as part of the PBM’s draft and/or final audit report?”, etc.  Comments should be sent directly to the Department at PBM@dfs.ny.gov by March 24, 2023, with “PBM2022-07” included in the subject line.

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

On March 14, NACDS will be joining the Pharmacists Society of the State of New York (PSSNY (Pharmacists Society of the State of New York)) in a rally in support of the Medicaid transition to fee-for-service. Beginning April 1, 2023, all Medicaid members enrolled in Mainstream Managed Care will receive their prescription drugs through NYRx, the Medicaid Pharmacy Program. The rally is to advocate to the legislature so no action would alter the planned transition.  

On March 21 at 1:00 p.m., the State Department of Health will be holding its next online seminar for all stakeholders about the pharmacy benefit transition. Members, providers and all interested stakeholders are welcome to attend regarding the transition.  

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

On February 21, the State Department of Health held an online seminar to update interested parties on the latest information regarding the Medicaid Pharmacy Benefit Transition from Managed Care to NYRx effective April 1. The next presentation and meeting will be March 21 at 1:00 p.m. 

Also in New York, the Department of Financial Services (Department) Pharmacy Benefits Bureau (“PBB”) announced a final request for public engagement as the Department looks to develop nation-leading regulatory standards for Pharmacy Benefit Managers (PBMs).  

This request asks for information on PBM audits of pharmacies, which are meant to eliminate or reduce fraud, waste, and abuse, but often are overly burdensome and costly without meeting this intended goal. Instead, pharmacy owners are taken away from providing healthcare, requiring them to review and defend claims from years in the past at the sole direction of PBMs without justification. The information collected will inform the scope of regulations necessary to ensure audits follow a clear and transparent process and have guardrails in place to meet the goal of preventing fraud, misuse, and waste. The Department is in the process of developing a series of PBM regulations that together will form the most comprehensive regulatory framework in the country. 

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