Medicaid Pharmacy Program

Announcements

MAT Formulary: Effective October 1, 2021, the Department of Health implemented a single statewide Medication Assisted Treatment (MAT) formulary for Opioid Antagonists and Opioid Dependence Agents across Medicaid Fee-for-Service (FFS) and Managed Care per the enacted budget for State Fiscal Year 2020-2021. For additional guidance regarding this implementation and to support troubleshooting, please review the Updated Guidance: Statewide Formulary for Opioid Dependence Agents and Opioid Antagonists within the MAT Formulary Resources & Materials section of the website below.

Pharmacy Carve-Out: The FY 2022 Enacted Budget delays the transition of the Medicaid pharmacy benefit by two years, until April 1, 2023.

Pharmacy Carve-Out:

This MRT II initiative will move the pharmacy benefit for over 5 million Medicaid managed care members back to fee-for-service (FFS). Transitioning pharmacy services from Managed Care to FFS will, among other things:

  • Provide the State with full visibility into prescription drug costs.
  • Centralize and leverage negotiation power.
  • Provide a single drug formulary with standardized utilization management protocols.
  • Address the growth of the 340B program and associated reductions in State rebate revenue.

Medication Assisted Treatment (MAT) Formulary:

Effective October 1, 2021, per the enacted NYS Budget for SFY 2020-2021, in accordance with §367-a (7)(e) of Social Services Law, the NYS DOH is implementing a single statewide Medication Assisted Treatment (MAT) formulary for Opioid Antagonists and Opioid Dependence Agents for NYS Medicaid fee-for-service (FFS) as well as Medicaid Managed Care (MMC). Under this statewide formulary, NYS Medicaid FFS and MMC will:

  • follow a single formulary when:
    • coverage parameters are consistent across the Medicaid Program,
    • preferred products are available without prior authorization (PA) when prescribed consistent with Food and Drug Administration (FDA) package labeling, and
    • non-preferred products require PA; as well as
  • use standard clinical criteria for approval of a non-preferred drug in accordance with §273 (3)(a) of Public Health Law.
  • Pharmacy Carve-Out
    • Medicaid Pharmacy Prior Authorization Programs Update & Practitioner Dispensing - (PDF) - January 2021
    • Medicaid Pharmacy Carve-Out - Special Edition:
    • Attention: Pharmacies, Durable Medical Equipment, Prosthetics, Orthotics and Supply Providers, and Prescribers That Are Not Enrolled in Medicaid Fee-For-Service (Pg. 10) - (PDF) - October 2020
  • MAT Formulary
    • Statewide Formulary for Opioid Dependence Agents and Opioid Antagonists - (PDF) - August 2021

Pharmacy Carve-Out

  • Member Notice of Change Reversal - (Web) - (PDF) Updated - 4.16.2021.
  • List of Physician Administered Drugs Added to the Medicaid List of Reimbursable Drugs - (Web) - (PDF) - Updated - 2.3.2021
  • 1557 Non-Discrimination and Language Services Templates - (PDF)
  • Member Notice of Change - (Web) - (PDF) Updated - 4.7.2021.
  • Transition & Communications Activities Timeline - (Web) - (PDF) - Updated - 5.18.2021
  • Frequently Asked Questions (FAQs) - (Web) - (PDF) - Updated - 5.18.2021
  • Scope of Benefits - (Web) - (PDF) Updated - 4.7.2021
  • Roles & Responsibilities - (Web) - (PDF) Updated - 4.7.2021

MAT Formulary

Presentations from All Stakeholder meetings:
Transition (Carve-Out) of the Pharmacy Benefit from Managed Care to Fee-for-Service (FFS):
Implementation Update & Strategy
340B Advisory Group Meetings
  • Meeting 1 - August 5, 2020 (updated) (PDF)
  • Meeting 2 - August 26, 2020 (PDF)
  • Meeting 3 - September 16, 2020 (PDF)
Presentations from All Stakeholder meetings:
Single Statewide Medication Assisted Treatment (MAT) Formulary
  • Meeting 1 - August 31, 2021 (PDF)