On December 22, 2021, Governor Hochul signed a new law that changes the Social Services Law and the Public Health Law, which relate to medication for the treatment of substance use disorders. Effective March 22, 2022, prior authorization (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.
A Single Statewide Medication Assisted Treatment (MAT) Formulary was put in place for Medicaid Managed Care Plans and Medicaid-Fee-for-Service in New York State on October 1, 2021. For more information, please visit the online Single Statewide MAT Formulary or download the summary of changes below.
Summary of Changes - English
DownloadSummary of Changes - Spanish
DownloadIf you would like to receive a specialty pharmacy drug from an in-network retail pharmacy rather than Kroger Specialty Pharmacy, you may choose any pharmacy in the plan’s retail network as long as that retail pharmacy is willing to accept comparable pricing. If you select a retail pharmacy that has not requested to be in the plan’s Specialty Pharmacy Network, and has not accepted comparable pricing, then the pharmacy should still attempt to adjudicate the claim. If your pharmacist is having difficulty processing a claim at the point-of-sale transaction, they should use the telephone number indicated on the reject message for further processing of the point-of-sale transaction. For a complete list of formulary drugs from SelectHealth by VNS Health, please refer to the SelectHealth Formulary and Formulary Changes.
In-network retail pharmacies interested in applying to the Specialty Pharmacy Network must submit a request by contacting MedImpact Healthcare Systems, Inc. at 1-888-678-7741 or [email protected]. To use your retail pharmacy for accessing specialty pharmacy drugs, please provide contact information, NPI, the name of the health plan you wish to join for specialty pharmacy networks and information regarding the member making the request.
Electronic messaging is provided to pharmacies to help redirect and resolve rejects through the MedImpact Healthcare Systems, Inc. adjudication system.
Last updated 9/6/2022
Effective December 20, 2022, all prescription formulations of ammonium lactate (ammonium lactate 12% topical cream and lotion) are removed from the formulary and excluded from NYS Medicaid Pharmacy Benefit. The New York State (NYS) Medicaid fee-for-service (FFS) and SelectHealth cover an extensive drug benefit providing access to medically necessary drugs. There are, however, certain drug/drug classes that are not covered by Medicaid for certain diagnoses due to federal or state rules as outlined in both the Social Security Act §1927(d)(2) and in the eMedNY New York State Medicaid Fee-for-Service Program Pharmacy Manual Policy Guidelines. Ammonium Lactate falls under “agents when used for cosmetic use or hair growth (additionally pursuant to NYCRR Title 18 §505.2(l)(5))”, which would exclude this drug from NYS Medicaid Pharmacy Benefit. Since excluded from NYS Medicaid Pharmacy coverage, prior authorization or exception for coverage requests will follow rules for exclusion during plan’s review. If not being used for cosmetic purposes, please speak to your prescriber about other treatment options.
