NYRx Medicaid Drug Program - Prior Authorization (PA) Programs Overview

Sep 25, 2026

NYRx Medicaid Drug Program guidance explains how prior authorization (PA) is required or waived under multiple clinical and cost-containment programs. It details electronic submission via CoverMyMeds, outlines the Preferred Drug Program (PDP) and Preferred Drug List (PDL), and describes Clinical Drug Review Program (CDRP) and Drug Utilization Review (DUR). Additional sections cover Medication Assisted Treatment (MAT) exceptions, Brand Less Than Generic (BLTG), Mandatory Generic rules, dose and cost optimization, and program-specific criteria for frequency, quantity, duration, and step therapy.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages86

Reading Time3 h 37 min

AccessFree to download

Overview of Contents

Electronic prior authorizations (CoverMyMeds)

Preferred Drug Program (PDP)

Clinical Drug Review Program (CDRP)

Drug Utilization Review (DUR) Program

Medication Assisted Treatment (MAT) Formulary

Brand Less Than Generic (BLTG) Program

Mandatory Generic Drug Program

Dose Optimization Program

Cost Optimization Program

Preferred Drug List - Table of Contents

OVERVIEW OF CONTENTS Electronic prior authorizations are now accepted by NYRx, the Medicaid Drug Program via CoverMyMeds® . Consider this alternative option as an effective and efficient way to request a PA other than by phone or by fax. For more information, contact NYRx Education & Outreach [at](at NYRxEO@primetherapeutics.com)[ ](at NYRxEO@primetherapeutics.com)[NYRxEO@primetherapeutics.com](at NYRxEO@primetherapeutics.com) Preferred Drug Program (PDP) (Pages 4–59) The PDP promotes the use of less expensive, equally effective drugs when medically appropriate through a Preferred Drug List (PDL) . All drugs currently covered by NYRx, the Medicaid Drug Program , remain available under the PDP and the determination of preferred and non-preferred drugs does not prohibit a prescriber from obtaining any of the medications covered under Medicaid. • Non-preferred drugs in these classes require prior authorization (PA), unless indicated otherwise. • Preferred drugs that require PA are indicated by footnote. • Specific Clinical, Frequency/Quantity/Duration, Step Therapy criteria are listed in column at the right. Note: Not all drugs covered by NYRx are subject to programs included in this document. For a complete list of drugs covered by NYRx see the Medicaid Pharmacy List of Reimbursable Drugs Clinical Drug Review Program (CDRP) (Page 60) The CDRP is aimed at ensuring specific drugs are utilized in a medically appropriate manner. Under the CDRP, certain drugs require PA because there may be specific safety issues, public health concerns, the potential for fraud and abuse, or the potential for significant overuse and misuse. Drug Utilization Review (DUR) Program (Pages 61–74) The DUR helps to ensure that prescriptions for outpatient drugs are appropriate, medically necessary, and not likely to result in adverse medical consequences. This program uses professional medical protocols and computer technology and claims processing to assist in the management of data regarding the prescribing and dispensing of prescriptions. Frequency/Quantity/Duration (F/Q/D) Program and Step Therapy parameters are implemented to ensure clinically appropriate and cost-effective use of these drugs and drug classes. Medication Assisted Treatment (MAT) Formulary (Page 75) PA will not be required for medications used for the treatment of substance use disorder prescribed according to generally accepted national professional guidelines for the treatment of a substance use disorder. Brand Less Than Generic (BLTG) Program (Pages 76–77) The Brand Less Than Generic Program is a cost containment initiative which promotes the use of certain multi-source brand name drugs when the cost of the brand name drug is less expensive than the generic equivalent. This program is in conformance with State Education Law, which intends that patients receive the lower cost alternative. Mandatory Generic Drug Program (Page 78) State law excludes Medicaid coverage of brand name drugs that have a Federal Food and Drug Administration (FDA) approved A-rated generic equivalent unless a PA is obtained. Drugs subject to the Preferred Drug Program (PDP), Clinical Drug Review Program (CDRP), and/or the Brand Less Than Generic (BLTG) Program are not subject to the Mandatory Generic Program. Dose Optimization Program (Pages 79–83) Dose optimization can reduce prescription costs by reducing the number of pills a patient needs to take each day. The Department has identified drugs to be included in this program, the majority of which have FDA approval for once-a-day dosing, have multiple strengths available in correlating increments at similar costs and are currently being utilized above the recommended dosing frequency. Cost Optimization Program (Page 84) The Cost Optimization Program focuses on new formulations and dosages of older drug products that are disproportionately priced to other strengths of the same drug or similar drugs in the same drug

FAQs

How can prior authorization (PA) requests be submitted to NYRx?

NYRx accepts electronic prior authorizations through CoverMyMeds. This is offered as an effective alternative to requesting by phone or fax.

What does the Preferred Drug Program (PDP) do?

The PDP promotes use of less expensive but equally effective drugs through a Preferred Drug List. Determinations of preferred and non-preferred status do not prevent a prescriber from obtaining medications covered under Medicaid.

Which programs may require PA even when medications are covered by Medicaid?

Non-preferred drugs generally require PA, and certain drugs under the Clinical Drug Review Program (CDRP) require PA due to safety, public health, fraud/abuse, or overuse/misuse concerns. Additional rules apply under DUR, BLTG, and the Mandatory Generic Drug Program.

Sep 25, 2026

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