2023 New York Laws › PBH - Public Health › Article 2-A - Prescription Drugs › Title 1 - Preferred Drug and Clinical Drug Review Programs › 273 - Preferred Drug Program Prior Authorization.

§ 273. Preferred drug program prior authorization. 1. For the purposes
of  this  article,  a prescription drug shall be considered to be not on
the preferred drug list if it is a non preferred drug.
2. The preferred drug program shall make available a twenty-four  hour
per  day,  seven  days  per  week  telephone call center that includes a
toll-free telephone line and dedicated  facsimile  line  to  respond  to
requests   for  prior  authorization.  The  call  center  shall  include
qualified health care professionals who shall be  available  to  consult
with  prescribers  concerning  prescription  drugs  that  are not on the
preferred drug list. A  prescriber  seeking  prior  authorization  shall
consult  with  the  program  call  line to reasonably present his or her
justification for the prescription  and  give  the  program's  qualified
health care professional a reasonable opportunity to respond.
3.    * (a)  When  a  patient's  health  care  provider  prescribes  a
prescription drug that  is  not  on  the  preferred  drug  list  or  the
statewide  formulary  of opioid dependence agents and opioid antagonists
established  pursuant  to  subparagraph  (vii)  of  paragraph   (e)   of
subdivision  seven  of section three hundred sixty-seven-a of the social
services law, the prescriber shall consult with the program  to  confirm
that  in  his  or  her  reasonable  professional judgment, the patient's
clinical condition is consistent with the criteria for approval  of  the
non-preferred drug. Such criteria shall include:
(i) the preferred drug has been tried by the patient and has failed to
produce the desired health outcomes;
(ii)  the  patient  has  tried  the preferred drug and has experienced
unacceptable side effects;
(iii) the patient has been stabilized  on  a  non-preferred  drug  and
transition to the preferred drug would be medically contraindicated; or
(iv)  other  clinical  indications  identified by the drug utilization
review board established pursuant to section three hundred sixty-nine-bb
of the social services law, which shall  include  consideration  of  the
medical  needs  of  special  populations,  including  children, elderly,
chronically ill, persons with  mental  health  conditions,  and  persons
affected  by  HIV/AIDS, pregnant persons, and persons with an opioid use
disorder.
* NB Effective until March 31, 2026
* (a) When a patient's health care provider prescribes a  prescription
drug  that  is  not  on  the  preferred  drug list, the prescriber shall
consult with the program to  confirm  that  in  his  or  her  reasonable
professional  judgment,  the  patient's clinical condition is consistent
with the criteria for approval of the non-preferred drug. Such  criteria
shall include:
(i) the preferred drug has been tried by the patient and has failed to
produce the desired health outcomes;
(ii)  the  patient  has  tried  the preferred drug and has experienced
unacceptable side effects;
(iii) the patient has been stabilized  on  a  non-preferred  drug  and
transition to the preferred drug would be medically contraindicated; or
(iv)  other  clinical  indications identified by the committee for the
patient's  use  of  the  non-preferred   drug,   which   shall   include
consideration  of  the  medical  needs of special populations, including
children,  elderly,  chronically  ill,  persons   with   mental   health
conditions, and persons affected by HIV/AIDS.
* NB Effective March 31, 2026
* (a-1)   When   a   patient's   health  care  provider  prescribes  a
prescription  drug  that  is  on  the  statewide  formulary  of   opioid
dependence   agents  and  opioid  antagonists  established  pursuant  to
subparagraph (vii) of paragraph (e)  of  subdivision  seven  of  section

three  hundred  sixty-seven-a of the social services law, the department
shall  not  require  prior  authorization   unless   required   by   the
department's  drug  use  review  program established pursuant to section
1927(g) of the Social Security Act.
* NB Repealed March 31, 2026
(b)  In  the  event  that  the  patient  does not meet the criteria in
paragraph (a) of this subdivision, the prescriber may provide additional
information to the program to justify the use  of  a  prescription  drug
that  is  not  on  the  preferred drug list. The program shall provide a
reasonable opportunity for a prescriber to reasonably present his or her
justification of prior authorization. If, after  consultation  with  the
program, the prescriber, in his or her reasonable professional judgment,
determines  that  the  use  of  a  prescription  drug that is not on the
preferred drug list is warranted, the prescriber's  determination  shall
be final.
(c)  If a prescriber meets the requirements of paragraph (a) or (b) of
this subdivision, the prescriber shall be  granted  prior  authorization
under this section.
(d)  In  the instance where a prior authorization determination is not
completed within twenty-four hours of the original  request,  solely  as
the  result of a failure of the program (whether by action or inaction),
prior authorization shall be immediately and automatically granted  with
no further action by the prescriber and the prescriber shall be notified
of  this  determination.  In  the  instance  where a prior authorization
determination is not completed within twenty-four hours of the  original
request  for  any  other  reason,  a  seventy-two  hour  supply  of  the
medication shall be approved by the program and the prescriber shall  be
notified of this determination.
4.  When,  in  the  judgment  of  the prescriber or the pharmacist, an
emergency condition exists, and the prescriber  or  pharmacist  notifies
the  program  that  an  emergency  condition  exists, a seventy-two hour
emergency supply of the drug prescribed shall be immediately  authorized
by the program.
5. In the event that a patient presents a prescription to a pharmacist
for  a  prescription drug that is not on the preferred drug list and for
which the  prescriber  has  not  obtained  a  prior  authorization,  the
pharmacist shall, within a prompt period based on professional judgment,
notify  the  prescriber.  The  prescriber  shall, within a prompt period
based on professional judgment, either seek prior authorization or shall
contact the  pharmacist  and  amend  or  cancel  the  prescription.  The
pharmacist shall, within a prompt period based on professional judgment,
notify  the patient when prior authorization has been obtained or denied
or when the prescription has been amended or cancelled.
6. Once prior authorization of a prescription for a drug that  is  not
on the preferred drug list is obtained, prior authorization shall not be
required for any refill of the prescription.
7.  No  prior  authorization under the preferred drug program shall be
required when a prescriber prescribes a drug on the preferred drug list;
provided, however, that the commissioner may identify such  a  drug  for
which  prior authorization is required pursuant to the provisions of the
clinical drug review  program  established  under  section  two  hundred
seventy-four of this article.
8.  The  department  shall monitor the prior authorization process for
prescribing patterns which are suspected of endangering the  health  and
safety  of  the  patient  or  which demonstrate a likelihood of fraud or
abuse. The department shall take any and all actions otherwise permitted
by law to investigate such prescribing patterns, to take remedial action
and to enforce applicable federal and state laws.
9. No prior authorization under the preferred drug  program  shall  be
required  for any prescription under EPIC until the panel has made prior
authorization applicable to EPIC under section two hundred  seventy-five
of this article.
10.  Prior  authorization  shall not be required for any buprenorphine
products,  methadone,  or  long   acting   injectable   naltrexone   for
detoxification  or  maintenance  treatment  of  a substance use disorder
prescribed  according  to  generally  accepted   national   professional
guidelines for the treatment of a substance use disorder.