New York Medicaid Limits In-Office Dispensing Reimbursement for AIDS and Cancer Protocols

Yesterday, the New York Department of Health clarified its position on reimbursement for in-office dispensing operations under the New York Medicaid Pharmacy Fee-for-Service ("FFS") Program. The guidance was issued in concert with New York Medicaid's carve out of its pharmacy benefit from managed care to FFS. The new reimbursement policy severely limits the scope of reimbursable products for cancer and AIDS patients in in-office dispensing settings. Namely, New York FFS Medicaid will no longer reimburse practitioners for drugs prescribed and dispensed in-office that are aimed at relieving side effects of cancer or AIDS treatment such as pain or nausea.

Per New York Medicaid FFS guidance, effective April 1, 2021, the program will reimburse practitioners under the following parameters:

• to supply antibiotics (to treat Chlamydia and other Sexually Transmitted Infections) to a patient for later use by the patient and/or the patient's sexual partners.
• pursuant to New York Education Law, New York licensed practitioners authorized to prescribe may dispense up to a 72-hour supply, or more than 72-hour supply when:
  • practicing in hospitals as defined in section twenty-eight hundred one of the Public Health Law;
  • the dispensing of drugs is at no charge to their patients;
  • their practices are situated ten miles or more from a registered pharmacy;
  • the dispensing of drugs is in a clinic, infirmary or health service that is operated by or affiliated with a post-secondary institution;
  • the dispensing of drugs is due to a medical emergency as defined in New York State Education Law Article 137 §6810(6);
  • the dispensing of drugs that are diluted, reconstituted or compounded by a prescriber;
  • the dispensing of allergenic extracts; or
  • the dispensing of drugs pursuant to an oncological or acquired immunodeficiency syndrome (AIDS) protocol:
    • An oncologic protocol is a written set of instructions to guide the administration of chemotherapy, immunotherapy, hormone therapy, and/or targeted therapy to patients for the treatment of cancer or tumors. It does not include protocols that cover drugs prescribed to relieve side effects of these therapies or to relieve distressing symptoms (such as nausea or pain).
    • An AIDS protocol is a written set of instructions to guide the administration of antiretroviral drugs to patients for the treatment of HIV infections or AIDS. It does not include protocols that cover medications prescribed to relieve side effects of these therapies or distressing symptoms (such as nausea or pain).

The guidance will undoubtedly have an impact on oncology and AIDS practices seeking reimbursement from New York Medicaid.

For more information regarding the New York Medicaid FFS guidance, please contact your Quarles & Brady attorney or:

• Roger N. Morris: (602) 229-5269 / roger.morris@quarles.com
• Nicholas H. Meza: (602) 229-5439 / nicholas.meza@quarles.com
• Ryan L. Torres: (317) 399-2813 / ryan.torres@quarles.com