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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

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.

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Herceptin Coverage Policy

Perjeta Coverage Policy

Xolair Coverage Policy