NYRx Pharmacy Benefit Transition:
Info Sheet for Advocates
Health Law Unit
Intake Line: 800-724-0490 x5822
April 1, 2023: Prescription drug benefit under MMC is transferring to NYRx
- Will affect individuals enrolled in Mainstream Managed Care plans, HARPs, and HIV-SNPs
- Does not apply to enrollees in MTLC, Essential Plan, or Child Health Plus
What if client hasn’t received notice of the transition?
- Notices should have been sent by MMC plans to all impacted enrollees in February 2023.
- Client can contact MMC plan and request a copy of the notice and for the letter translated in their preferred language.
What should clients do if they find out their pharmacy benefit has transferred to NYRx?
- Check that their pharmacy or medical equipment supplier is enrolled in NYRx.
- Search tool: https://member.emedny.org/pharmacy/search-locations
- If not, ask pharmacist or provider to send prescription to a participating NYRx pharmacy.
- Check whether their drugs and supplies are covered by NYRx and if they will need prior authorization.
Where can a client find the Preferred Drug List (PDL) for NYRx?
- The Preferred Drug List (PDL)contains a listing of drugs/classes subject to the NYRx Pharmacy Program.
- Column 1: Preferred drugs > prior authorization not required (unless otherwise indicated)
- Column 2: Non-preferred drugs > prior authorization required (unless otherwise indicated)
- Column 3: Lists any special clinical criteria, frequency/quantity/duration or step therapy criteria
- For the full list of reimbursable drugs under the fee-for-service Medicaid Pharmacy Program, see: https://www.emedny.org/info/formfile.aspx
What if a client already has Prior Authorization approved by their MMC plan?
- All approved prior authorizations from managed care plans that are still active/valid after April 1, 2023, will be honored and transferred to NYRx.
- If there is an issue at point of service for a drug or supply that has already been approved, ask pharmacist to call the Magellan call center at 1-877-309-9493.
Is there a transition period after April 1, 2023?
- From April 1, 2023, through June 30, 2023, individuals may receive a one-time, temporary fill for up to a 30-day supply of a drug that would normally require prior authorization under NYRx.
- If there is an issue at point of service obtaining the transition fill, ask pharmacist to call the Magellan call center at 1-877-309-9493.
- After receiving one-time temporary fill for a non-preferred drug or supply, clients must:
- Talk to their prescribing provider or pharmacist about switching to an alternate drug or supply that does not require approval and is covered by NYRx; or
- Talk to their prescribing provider about submitting request for prior authorization to NYRx.
What is the prior authorization process for NYRx?
- Client’s prescribing provider must initiate the prior authorization process:
- PREFERRED METHOD: Call the Magellan Call Center, 1-877-309 9493, option 1 (prescriber). Call Center is operational 27 hours a day, 7 days per week
- Fax requests are permitted, but may take 24 hours to process – Standard form available here, fax to 1-800-268 2290
- NYRx anticipates that most prior authorization requests will be approved during a single call (verbal approval and NYRx system updated in real-time)
- Prescriber speaks to pharmacy technician, collects relevant info/asks clinical criteria questions
- If technician can’t approve, escalation to pharmacist for “more in-depth clinical conversation”
- If pharmacist can’t approve, escalation to peer-to-peer consultation
Is it possible to receive an emergency fill without prior authorization?
- Client needs medication right away and pharmacy can’t reach provider to initiate prior authorization process
- With valid prescription, pharmacist may provide up to a 3-day emergency supply of medication by completing emergency authorization process
- Tell pharmacist to call the Magellan call center 1-877-309 9493
What happens if prior authorization is denied?
- If prior authorization is denied, client should receive notice of denial and fair hearing rights apply:
- Request Fair Hearing within 60 days from the date of the denial https://otda.ny.gov/hearings/request/.
- Denial is not coming from the MMC plan, so contacting the client’s MMC plan will not start any appeal process.
- From NYRx: “By leveraging NYRx’s Prior Authorization request process, most of these issues can be addressed without utilizing the fair hearing process”.
Prescriber prevails in NYRx
- After consultation with NYRx, if the client’s prescriber determines that use of the prescription drug that is not on the PDL is warranted, the prescriber’s determination shall be final
- Applies for every drug category in fee for service Medicaid (compare with only certain categories in MMC)
- Prescriber will still be required to provide NYRx with requested info and/or clinical documentation to support prior authorization requests
NYRx Medicaid Helpline for members
- For help by phone: 855 648 1909: TTY 1-800-662 1220
- Helpline hours: Mon-Fri 8AM-8PM; Sat 9AM-1PM
- Language assistance is available
- By email: NYRx@health.ny.gov
NYRx issue spotting/case escalation by advocates
Medicaid Matters New York has been asked by the NYS Department of Health to participate in a “command center” to bring issues with the transition of the pharmacy benefit to their attention.
Should you or someone you work with experience any difficulty with accessing prescriptions after the April 1 transition date or if you identify any issues that relate to the NYRx Transition, please complete this form to report:
Welcome to the NY Medicaid Pharmacy Program (NYRx)
Transition of the Pharmacy Benefit from Managed Care (MC) to Medicaid NYRx Pharmacy Program: Frequently Asked Questions (FAQs)
Pharmacy Transition Document Repository
NYRx Member Dashboard