N.Y. Comp. Codes R. & Regs. tit. 9 § 9960.2

Current through Register Vol. 46, No. 50, December 11, 2024

Section 9960.2 - Process for allowing coverage of excluded drugs

(a) Request for coverage.

(1) Any drug package, or form of dosage or administration excluded from coverage as a benefit under EPIC pursuant to section 9960.3 of this Part may be allowed to be dispensed to a specific eligible participant based upon a written request for coverage by a licensed physician and a legal prescription.

(2) Each request for coverage shall be supported by a written certification and specific reasons why an excluded drug package or form of dosage or administration is considered by a licensed physician to be medically indicated for treatment of a specific patient.

(3) Requests for coverage pursuant to paragraph (1) of this subdivision shall be made only by a licensed physician treating an eligible participant for whom such excluded drug benefit is considered to be medically indicated.

(4) All requests for coverage of an excluded drug benefit shall be supported by information submitted by a physician on a Drug Application Information form and submitted to the department. Telephone requests may be made to the department; however, all such telephone requests for information shall be followed by submission of the required information on a completed Drug Application Information form to facilitate proper review and disposition of each request.

(b) Drug Application Information form.

(1) Information to support a certification by a licensed physician as to the medical indication for treating an eligible participant with a drug considered to be an excluded drug shall be contained on a Drug Application Information form. Such information shall include the following:

(i) name of drug, dosage form, strength and name of marketer;

(ii) name and identification number of participant;

(iii) length of time physician has treated the participant;

(iv) name of illness/disease/condition being treated;

(v) length of time participant has been taking the drug requested;

(vi) list of other medications used to treat the participant;

(vii) specific reasons why requested drug is medically indicated;

(viii) medical consequences if excluded drug is not provided as a covered drug benefit;

(ix) identification and signature of the licensed physician treating the participant.

(2) Copies of the Drug Application Information form shall be made available by the department, or from local county offices for the aging or health departments, or the EPIC executive director or EPIC contractor.

(c) Decisions on coverage.

(1) Upon receipt of a completed Drug Application Information form submitted by a licensed physician, the department shall review the request and render a decision within three working days. Failure to render a decision within this time period shall not constitute approval by the department.

(2) Written notice of the decision shall be sent by the department to the licensed physician who requested coverage of an excluded drug for a particular eligible participant within seven working days following such decision. Similar written notice shall also be provided to the EPIC contractor by the EPIC executive director and to the participant to inform such person of this individual rights to be reimbursed for an excluded drug which is determined to be included as a covered benefit.

N.Y. Comp. Codes R. & Regs. Tit. 9 § 9960.2