(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* NB Repealed March 31, 2026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.