DOH Expands Managed Care Prescriber Prevails to Additional Classes

NYAPRS Note: The following comes this afternoon from the NYS Department of Health affirming that starting this July, additional prescription drug classes that were approved in this year’s legislative session will be available to those beneficiaries whose prescriber believes are medically warranted. Note that SSRI and SNRI antidepressants and 2nd generation anticonvulsants, which some of our community members take for mood related conditions, are now back in the prescriber prevails program, joining atypical anti-psychotics which remain in the program since January 2012 after the legislature rejected proposals to take them out.


Expanding Prescriber Prevails in Medicaid Managed Care in Certain Drug Classes


Effective July 1, 2013, for Medicaid Managed Care Plans, the “prescriber prevails” provision will be expanded to include medically necessary prescription drugs in the anti-depressant, antiretroviral, anti-rejection, seizure, epilepsy, endocrine, hematologic and immunologic therapeutic classes,* including non-formulary drugs, upon demonstration by the prescriber, after consulting with the managed care provider, that such drugs, in the prescriber's reasonable professional judgment, are medically necessary and warranted. This change is the result of legislation passed in the 2013-2014 Executive Budget. Once implemented, this initiative will enable the prescriber's reasonable professional judgment to prevail for the above therapeutic drug classes that are not on plan formularies or have prior authorization requirements.


Plans will continue to develop formularies and may also administer prior authorization programs for these therapeutic drug classes. Prescribers will still be required to supply plans with requested information and/or clinical documentation. As they do currently, plans will be able to provide a temporary (3 day) supply of medication when necessary.


Pursuant to federal and contractual provisions, the plans will continue to be required to meet specified turnaround times. Additionally, notices will be sent to members and prescribers for prior authorization requests where the plan is unable to make a determination due to missing information or the prescriber’s reasonable professional judgment has not been adequately demonstrated. In such cases, members’ rights regarding appeals and fair hearings will continue to apply. This is consistent with plans’ current processes for member and provider notification.


*NOTE: Stakeholders can match affected drugs to the Medicaid Fee for Service (FFS) Preferred Drug List (PDL) for quick identification when prescribing. Below is a crosswalk for comparison.


2013-2014 Expanded Prescriber Prevails classes based on current Medicaid FFS PDL


Hematological Agents*

Anticoagulants- Injectable

Anticoagulants- Oral

Erythropoiesis Stimulating Agents (ESAs)

Platelet Inhibitors


Central Nervous System


Anticonvulsants- Second Generation

Benzodiazepines- Rectal

Carbamazepine Derivatives

Immunologic Agents*

Multiple Sclerosis Agents


Selective Serotonin Reuptake Inhibitors (SSRIs)

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)


Endocrine and Metabolic Agents*

Amylin Analogs

Anabolic Steroids- Topical


Bisphosphonates- Oral

Calcitonins- Intranasal

Dipeptidyl Peptidase- 4 (DPP-4) Inhibitors

Glucagon-like Peptide-1 (GLP-1) Agonists

Growth Hormones

Insulin- Long-Acting

Insulin- Mixes

Insulin- Rapid-Acting

Pancreatic Enzymes

Thiazolidinediones (TZDs)


Immunologic Agents*

Immunomodulators- Systemic


2013-2014 Expanded Prescriber Prevails classes not currently on Medicaid FFS PDL


Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome

(AIDS) Agents


Immunosuppressives- Oral