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. Under this statewide formulary, Medicaid FFS and Managed Care members will follow a single formulary and coverage parameters are consistent across the Medicaid Program. For additional guidance regarding this implementation and to support troubleshooting, please review the MAT Formulary 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:

The New York State Executive Budget for State Fiscal Year 2020-2021, in accordance to § 367-a (7) (e) of Social Services Law, enacts a statewide formulary for Opioid Antagonists and Opioid Dependence Agents for Medicaid Managed Care (MC) Plans and Medicaid Fee for Service (FFS) Program. Under this statewide formulary, Medicaid MC and FFS members will follow a single formulary and coverage parameters are consistent across the Medicaid Program.

On December 22, 2021, Governor Hochul signed Chapter 720 of the Laws of 2021. This law amends Social Services Law and the Public Health Law, in relation to medication for the treatment of substance use disorders. Effective March 22, 2022, prior authorization will not be required for medications used for the treatment of substance use disorder when prescribed according to generally accepted national professional guidelines for the treatment of a substance use disorder.

  • 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
    • Updated Statewide Formulary for Opioid Dependence Agents and Opioid Antagonists - (PDF) - February 2022
    • 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)