§ 273 — Preferred drug program prior authorization

§ 273. Preferred drug program prior authorization. 1. For the purposes\nof this article, a prescription drug shall be considered to be not on\nthe preferred drug list if it is a non preferred drug.\n 2. The preferred drug program shall make available a twenty-four hour\nper day, seven days per week telephone call center that includes a\ntoll-free telephone line and dedicated facsimile line to respond to\nrequests for prior authorization. The call center shall include\nqualified health care professionals who shall be available to consult\nwith prescribers concerning prescription drugs that are not on the\npreferred drug list. A prescriber seeking prior authorization shall\nconsult with the program call line to reasonably present his or her\njustification for the prescription and give the program's qualified\nhealth care professional a reasonable opportunity to respond.\n 3. * (a) When a patient's health care provider prescribes a\nprescription drug that is not on the preferred drug list or the\nstatewide formulary of opioid dependence agents and opioid antagonists\nestablished pursuant to subparagraph (vii) of paragraph (e) of\nsubdivision seven of section three hundred sixty-seven-a of the social\nservices law, the prescriber shall consult with the program to confirm\nthat in his or her reasonable professional judgment, the patient's\nclinical condition is consistent with the criteria for approval of the\nnon-preferred drug. Such criteria shall include:\n (i) the preferred drug has been tried by the patient and has failed to\nproduce the desired health outcomes;\n (ii) the patient has tried the preferred drug and has experienced\nunacceptable side effects;\n (iii) the patient has been stabilized on a non-preferred drug and\ntransition to the preferred drug would be medically contraindicated; or\n (iv) other clinical indications identified by the drug utilization\nreview board established pursuant to section three hundred sixty-nine-bb\nof the social services law, which shall include consideration of the\nmedical needs of special populations, including children, elderly,\nchronically ill, persons with mental health conditions, and persons\naffected by HIV/AIDS, pregnant persons, and persons with an opioid use\ndisorder.\n * NB Effective until March 31, 2026\n * (a) When a patient's health care provider prescribes a prescription\ndrug that is not on the preferred drug list, the prescriber shall\nconsult with the program to confirm that in his or her reasonable\nprofessional judgment, the patient's clinical condition is consistent\nwith the criteria for approval of the non-preferred drug. Such criteria\nshall include:\n (i) the preferred drug has been tried by the patient and has failed to\nproduce the desired health outcomes;\n (ii) the patient has tried the preferred drug and has experienced\nunacceptable side effects;\n (iii) the patient has been stabilized on a non-preferred drug and\ntransition to the preferred drug would be medically contraindicated; or\n (iv) other clinical indications identified by the committee for the\npatient's use of the non-preferred drug, which shall include\nconsideration of the medical needs of special populations, including\nchildren, elderly, chronically ill, persons with mental health\nconditions, and persons affected by HIV/AIDS.\n * NB Effective March 31, 2026\n * (a-1) When a patient's health care provider prescribes a\nprescription drug that is on the statewide formulary of opioid\ndependence agents and opioid antagonists established pursuant to\nsubparagraph (vii) of paragraph (e) of subdivision seven of section\nthree hundred sixty-seven-a of the social services law, the department\nshall not require prior authorization unless required by the\ndepartment's drug use review program established pursuant to section\n1927(g) of the Social Security Act.\n * NB Repealed March 31, 2026\n (b) In the event that the patient does not meet the criteria in\nparagraph (a) of this subdivision, the prescriber may provide additional\ninformation to the program to justify the use of a prescription drug\nthat is not on the preferred drug list. The program shall provide a\nreasonable opportunity for a prescriber to reasonably present his or her\njustification of prior authorization. If, after consultation with the\nprogram, the prescriber, in his or her reasonable professional judgment,\ndetermines that the use of a prescription drug that is not on the\npreferred drug list is warranted, the prescriber's determination shall\nbe final.\n (c) If a prescriber meets the requirements of paragraph (a) or (b) of\nthis subdivision, the prescriber shall be granted prior authorization\nunder this section.\n (d) In the instance where a prior authorization determination is not\ncompleted within twenty-four hours of the original request, solely as\nthe result of a failure of the program (whether by action or inaction),\nprior authorization shall be immediately and automatically granted with\nno further action by the prescriber and the prescriber shall be notified\nof this determination. In the instance where a prior authorization\ndetermination is not completed within twenty-four hours of the original\nrequest for any other reason, a seventy-two hour supply of the\nmedication shall be approved by the program and the prescriber shall be\nnotified of this determination.\n 4. When, in the judgment of the prescriber or the pharmacist, an\nemergency condition exists, and the prescriber or pharmacist notifies\nthe program that an emergency condition exists, a seventy-two hour\nemergency supply of the drug prescribed shall be immediately authorized\nby the program.\n 5. In the event that a patient presents a prescription to a pharmacist\nfor a prescription drug that is not on the preferred drug list and for\nwhich the prescriber has not obtained a prior authorization, the\npharmacist shall, within a prompt period based on professional judgment,\nnotify the prescriber. The prescriber shall, within a prompt period\nbased on professional judgment, either seek prior authorization or shall\ncontact the pharmacist and amend or cancel the prescription. The\npharmacist shall, within a prompt period based on professional judgment,\nnotify the patient when prior authorization has been obtained or denied\nor when the prescription has been amended or cancelled.\n 6. Once prior authorization of a prescription for a drug that is not\non the preferred drug list is obtained, prior authorization shall not be\nrequired for any refill of the prescription.\n 7. No prior authorization under the preferred drug program shall be\nrequired when a prescriber prescribes a drug on the preferred drug list;\nprovided, however, that the commissioner may identify such a drug for\nwhich prior authorization is required pursuant to the provisions of the\nclinical drug review program established under section two hundred\nseventy-four of this article.\n 8. The department shall monitor the prior authorization process for\nprescribing patterns which are suspected of endangering the health and\nsafety of the patient or which demonstrate a likelihood of fraud or\nabuse. The department shall take any and all actions otherwise permitted\nby law to investigate such prescribing patterns, to take remedial action\nand to enforce applicable federal and state laws.\n 9. No prior authorization under the preferred drug program shall be\nrequired for any prescription under EPIC until the panel has made prior\nauthorization applicable to EPIC under section two hundred seventy-five\nof this article.\n 10. Prior authorization shall not be required for any buprenorphine\nproducts, methadone, or long acting injectable naltrexone for\ndetoxification or maintenance treatment of a substance use disorder\nprescribed according to generally accepted national professional\nguidelines for the treatment of a substance use disorder.\n