N.Y. Public Health Law 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.
Terms Used In N.Y. Public Health Law 273
- Board: shall mean the drug utilization review board. See N.Y. Public Health Law 270
- Clinical drug review program: means the clinical drug review program created by section two hundred seventy-four of this article. See N.Y. Public Health Law 270
- drug: means a drug defined in subdivision seven of § 6802 of the education law, for which a prescription is required under the federal food, drug and cosmetic act. See N.Y. Public Health Law 270
- Emergency condition: means a medical or behavioral condition as determined by the prescriber or pharmacists, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, and for which delay in beginning treatment prescribed by the patient's health care practitioner would result in:
(a) placing the health or safety of the person afflicted with such condition or other person or persons in serious jeopardy;
(b) serious impairment to such person's bodily functions;
(c) serious dysfunction of any bodily organ or part of such person;
(d) serious disfigurement of such person; or
(e) severe discomfort. See N.Y. Public Health Law 270 - Fraud: Intentional deception resulting in injury to another.
- Non preferred drug: means a prescription drug that is included in the preferred drug program and is not one of the drugs on the preferred drug list because it is either: (a) in a therapeutic class that is included in the preferred drug program and is not one of the drugs on the preferred drug list in that class or (b) manufactured by a pharmaceutical manufacturer with whom the commissioner is negotiating or has negotiated a manufacturer agreement and is not a preferred drug under a manufacturer agreement. See N.Y. Public Health Law 270
- Panel: means the elderly pharmaceutical insurance coverage panel established pursuant to § 244 of the elder law. See N.Y. Public Health Law 270
- Preferred drug: means a prescription drug that is either (a) in a therapeutic class that is included in the preferred drug program and is one of the drugs on the preferred drug list in that class or (b) a preferred drug under a manufacturer agreement. See N.Y. Public Health Law 270
- Preferred drug program: means the preferred drug program established under section two hundred seventy-two of this article. See N.Y. Public Health Law 270
- Prior authorization: means a process requiring the prescriber or the dispenser to verify with the applicable state public health plan or its authorized agent that the drug is appropriate for the needs of the specific patient. See N.Y. Public Health Law 270
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 § 367-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 § 369 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 § 367-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.