Medicaid Drug Coverage

Formulary & Drug Lists for Medicaid Members

Medication-Assisted Treatment (MAT) Formulary Change

The New York State Department of Health (NYSDOH) has created a new list of covered prescription drugs (also known as a formulary). This formulary will be used for the treatment of opioid dependence, and agents used to reverse an opioid overdose. The change will begin on October 1, 2021. Under the formulary, Medicaid Fee-For-Service and Medicaid Managed Care Members will follow a single formulary, where coverage parameters are consistent across the Medicaid Program. Certain preferred prescription drugs will also be available without a prior authorization.

This table shows which drugs are preferred and non-preferred:

	Preferred	Non-Preferred
Opioid Antagonists	Naloxone Naltrexone Narcan (nasal spray)
Opioid Dependence Agents – oral/transmucosal	Buprenorphine/naloxone sublingual tablets Suboxone Buprenorphine for induction only	Bunavail Zubsolv Buprenorphine/naloxone film
Opioid Dependence Agents – Physician administered	Methadone (maintenance at a certified clinic) Sublocade Vivitrol	Probuphine

Preferred

Non-Preferred

Opioid Antagonists

Naloxone

Naltrexone

Narcan (nasal spray)

Opioid Dependence Agents – oral/transmucosal

Buprenorphine/naloxone

sublingual tablets

Suboxone

Buprenorphine for induction only

Bunavail

Zubsolv

Buprenorphine/naloxone film

Opioid Dependence Agents – Physician administered

Methadone (maintenance at a certified clinic)

Sublocade

Vivitrol

Probuphine

What does this mean for CDPHP members?

Starting October 1, 2021, CDPHP® will cover buprenorphine/naloxone sublingual tablets, brand-name Suboxone films (buprenorphine/naloxone films), and buprenorphine sublingual tablets (to be used for induction only) without a prior authorization. Members currently on generic buprenorphine/naloxone film can continue to go to the pharmacy and the pharmacist is able to make the change to the brand drug.
Members who are currently on Zubsolv (buprenorphine/naloxone tablets) or buprenorphine sublingual tablets (as maintenance therapy) will need to get a new prescription from their provider. Letters will be sent to all impacted members and providers by September 3, 2021.
If a member or a provider determines that a change cannot be made at this time, a prior authorization request will be required to continue on non-preferred products. Prior authorization requests must include clinical documentation to support the use of the non-preferred product.

Formulary & Drug Lists for Medicaid Members

Medicaid Formulary (Drug List)
A formulary is a list of covered drugs. The Medicaid formulary is a useful reference to assist practitioners in selecting clinically appropriate and cost-effective drug therapies.
Medicaid Formulary Updates
The Medicaid Formulary Updates includes drug products were reviewed and acted upon by the CDPHP Pharmacy and Therapeutics Committee for Medicaid Formulary.
Medicaid Over-The-Counter (OTC) Drug List
The CDPHP Medicaid Over-The Counter (OTC) list represents select over the counter medications or products that may be covered with a prescription and at a network participating pharmacy. Quantity limits may apply.
Medicaid Prior Authorization Request Form for Prescriptions
The Medicaid Prior Authorization Request Form for Prescriptions is to be completed by prescribing doctors when providing prior authorization or when requesting a formulary exception.