As referenced in the 1% Across the Board (ATB) Medicaid Rate Increase, the New York State Department of Health revised the Medicaid Fee-for-Service (FFS) pharmacy professional dispensing fee to comply with this change. Effective September 22, 2022, the professional dispensing fee will change from $10.08 to $10.18 for covered outpatient drugs, when applicable. This was based on the enacted budget and was effectuated by Centers for Medicare and Medicaid Services (CMS) state plan approval. This does include retroactive adjustments to the dispensing fee back to April 1, 2022. Those adjustments will be processed at a future date, details will be forthcoming.

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

The Medicaid Department updated the Medicaid Fee-for-Service Providers Dispense Brand Name Drug when Less Expensive than Generic Program. 

Effective 10/6/2022, the following changes will be made to the Dispense Brand Name Drug 

When Less Expensive Than the Generic Program: 

• Daytrana, Nexavar, Pradaxa and Ventolin HFA will be ADDED to the program
• ProAir HFA will be REMOVED from the program.

In conformance with State Education Law, which intends patients receive the lower cost drug 

alternative, 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.

IMPORTANT BILLING INFORMATION 

Pursuant to this program, prescription claims submitted to the Medicaid program do not require the submission of Dispense as Written/Product Selection Code of ‘1’; Pharmacies should submit DAW code 9 (Substitution Allowed by Prescriber but Plan Requests Brand). Pharmacies will receive a NCPDP (National Council for Prescription Drug Programs) reject response of “22” which means missing/invalid DAW code if other DAW codes are submitted. The only exception to this, is DAW code 1 and “Brand Medically Necessary” on the prescription. 

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

Governor Kathy Hochul (D) issued an executive order that declares a state of emergency due to the spread of the monkeypox virus and directs all relevant state agencies to assist local governments in responding to the outbreak.

The executive order grants healthcare providers, including pharmacists, emergency permission to administer monkeypox vaccines through August 28, 2022.

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

As you are aware, late in 2021 several PBM legislative packages were signed into law. Now as the NYS Department of Financial Services is developing regulations, the Department is seeking public comment on a series of issues. Those requests for comments can be found on the Department of Financial Services website:  www.dfs.ny.gov/pbm.

 The most recent Department request is for public comments about the applicability of the Pharmacy Benefit Manager (“PBM”) laws set forth in New York Insurance Law Article 29, as well as the need for rules to be promulgated thereunder, on PBM conduct while credentialing and re-credentialing pharmacies into a PBM network. View the Request for Public Comments (PDF)

Responses should be emailed to PBM@dfs.ny.gov, with “PBM2022-05” included in the subject line. Failure to include “PBM2022-05” in the subject line may result in your comment not being considered. The deadline for responses is September 9, 2022.

Also in New York, NYS Medicaid recently held a pharmacy sector meeting and discussed the work being done to ensure a smooth transition for pharmacy benefits from Medicaid Managed Care to Fee for Service (FFS). Here are the NYSDOH Pharmacy Benefit transition slides presented at the July 20^th Medicaid meeting.

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

As a result of PBM legislation enacted in 2021, the NYS Department of Financial Services is developing regulations, and the Department is seeking public comment on a series of issues.  

Below are the three upcoming Public Notices with links for more details related to: 

PBM Services to Medicare Part D Plans, Comments due August 1, 2022  

View the Request for Public Comments (PDF) Responses should be emailed to PBM@dfs.ny.gov, with “PBM2022-02” included in the subject line. Failure to include “PBM2022-02” in the subject line may result in your comment not being considered. The deadline for responses is August 1, 2022.  

Reporting Requirements for PBMs (Pharmacy Benefits Managers), Comments due August 5, 2022 

View the Request for Public Comments (PDF) Responses should be emailed to PBM@dfs.ny.gov, with “PBM2022-03” included in the subject line. Failure to include “PBM2022-03” in the subject line may result in your comment(s) not being considered. The deadline for responses is August 5, 2022. 

Practice of Patient Steering by PBMs due August 19, 2022 

View the Request for Public Comments (PDF) Responses should be emailed to PBM@dfs.ny.gov, with “PBM2022-04” included in the subject line. Failure to include “PBM2022-04” in the subject line may result in your comment not being considered. The deadline for responses is August 19, 2022.  

For more information about these Public Notices and DFS (Department of Financial Services) efforts to implement the law, please click here. 

Also in New York, the Office of the Medicaid Inspector General (OMIG) published a Proposed Rule Making in the State Register related to Medicaid Program Fraud, Waste and Abuse Prevention with the stated purpose to establish requirements for providers to detect and prevent fraud, waste, and abuse in the Medicaid Program.  

The full text of the proposed rule can be found here. Public comments are due within 60 days from when published on July 13, 2022. To read the new sections added to OMIG regulation through this rulemaking in their entirety, please click here. 

In particular, the proposed rulemaking would repeal and add a new 18 NYCRR Part 521 to implement statutory changes resulting from the recommendations of the Medicaid Redesign Team II as adopted in the State Fiscal Year 2020-2021 Enacted Budget (Chapter 56 of the Laws of 2020, Part QQ) and to make other conforming changes related to: 

(1) Provider Compliance Programs,  

(2) Medicaid Managed Care Plan fraud, waste, and abuse prevention programs under the Medical Assistance (Medicaid) program, and  

(3) The Obligation to report, return and explain Medicaid overpayments through OMIG’s Self-Disclosure Program.  

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

On June 8, 2022, the New York State Department of Health in consultation with the Department of Environmental Conservation, announced the approval of two Drug Take-Back programs, proposed and operated by Inmar Rx Solutions, Inc. and MED-Project, LLC. Pursuant to Chapter 120 Laws of 2018, the New York State Drug Take Back Act (DTB) mandates that manufacturers establish, fund, and manage a New York State-approved drug take-back program(s) for the safe collection and disposal of unused covered drugs. Pharmacies of ten or more establishments within NYS and non-resident pharmacies that provide covered drugs to NYS residents by mail must implement such programs by providing consumers with a pre-approved method(s) of collection and disposal, free of charge to the consumer and pharmacy. 

For more information on the Drug Take-Back programs to be operated by Inmar and MED-Project, visit their sites: 

• Inmar 
• MED-Project 

The press release can be found here: New York State Department of Health and Department of Environmental Conservation Announce Approval of Two Drug Take Back Programs 

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

Before the New York State Legislature recently adjourned, both Houses passed legislation (A3040B-S4807B) which would authorize pharmacists to administer long-acting injectable medication for MH/SUD per a prescription or order. In addition, the legislature rejected efforts to delay or repeal the planned FFS (Fee for Service) transition of the pharmacy benefit set to take effect on April 1, 2023. 

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

The Office of Health Insurance Programs of the New York State Department of Health has approved the release of the March 2022 Medicaid Update.  

You may also go straight to an article or topic that pertains to you by selecting it from the current issue’s table of contents below.  

 Policy and Billing 

• Early and Periodic Screening, Diagnostic, and Treatment Program Childhood Vaccine Counseling Coverage Benefit (Cover) 
• New York State Medicaid Professional Pathology Policy 
• Attention: New York State Medicaid Fee-For-Service Providers Administering Drugs 
• Pharmacy and Medical Billing Guidance for SPRAVATO® (esketamine) 
• Discontinued Coverage for TerSera Therapeutics LLC Drugs 
• COVID-19 Testing, Therapeutics, Vaccine Administration, and Vaccine Counseling Policy Reminders 

All Providers 

• Medicaid Consumer Fact Sheets Now Available 
• Official Launch of eMedNY Provider Enrollment Portal 
• New York State Medicaid Launches Emergency Triage, Treat, and Transport Program 
• NY State of Health: Affordable Care Act 12th Anniversary; Congress Encouragement to Extend American Rescue Plan Tax Credits; Medicaid Resumes Eligibility Reviews, Disenrolled Members Should Be Directed to the Marketplace 
• New York State Department of Health Medicaid Accelerated eXchange (MAX) Workshop Series: Register for Round Two and Upcoming Informational Webinar 
• Medicaid Breast Cancer Surgery Centers 

Pharmacy 

• Update on Pharmacy Billing for Compound Prescriptions 

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

The State Education Department regulation expanding the pharmacist immunization authority which took effect on January 31, 2022, is set to expire on April 10. At the last Board of Regents meeting, the Board took emergency action effective April 11 to keep the regulation in effect until it can be permanently adopted at the Board May Meeting.

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