COVID-19 Guidance for Medicaid Providers
- Guidance is also available in Portable Document Format (PDF)
Medicaid Pharmacy Guidance Regarding the Declared Disaster Emergency in the State of New York - COVID-19
As of 4/6/2020
Updates are highlighted
Effective July 9, 2021, in accordance with the end of the State Disaster Emergency declared on March 7, 2020 to fight COVID-19, this guidance has expired.
The following guidance is effective until the official Declared Disaster Emergency in the State of New York over COVID-19 has ended.
- 90 Day Supplies & Medication Delivery: Medicaid covers a 90-day supply for most prescription and over the counter (OTC) maintenance medications, in accordance with State and federal laws. Where practicable, practitioners and pharmacists should utilize 90-day supplies of long-term maintenance medications for individuals in quarantine, shelter in place, or those that have been identified by the CDC as being at a higher risk for developing serious illness from COVID-19. In the event of supply chain interruptions, medications for these populations should be prioritized.
- ✓ To ensure adequate supply for high-demand products, practitioners and pharmacists should continue to prioritize 90-day supplies for the populations mentioned above. This will assist in addressing the demand, while ensuring a safe and stable supply chain.
- ✓ If confirmation of delivery was initiated by one of the methods above, but the member could not be reached via phone, text or email, this should be documented within the pharmacy´s processing system as "Emergency COVID-19-Unable to Confirm Delivery."
- Drug Supplies
- ✓ Prescription drug supplies are being monitored for potential backorders and prior authorization requirements may be removed for alternative available products, in order to improve access.
- ✓ Over the Counter (OTC) products are being monitored and coverage for certain products/forms may be added, as needed.
- ✓ Specific removals of prior authorization or addition of OTC products will be shared via separate email blasts and on the Medicaid Administration NYS Medicaid Pharmacy Programs page.
- Transfers: If a Medicaid member has had a prescription filled from a pharmacy that is inaccessible or traveling to that pharmacy is not feasible, he/she can obtain a new prescription/fiscal order from the prescriber or a refill of the prescription can be transferred to another Medicaid participating pharmacy (where allowed by law).
- Early Fills: Early refills for members in need of medications due to quarantine or outbreak (controlled substances and non-controlled substances) will be allowed, per the provider´s discretion, in accordance with State and federal laws. An early fill response will be returned when a prescription claim is transmitted prior to the date when either 75 percent of the previous supply would have been used or an extra 10 days´ supply of medication has been obtained over the last 90 days if taken according to the prescriber´s directions. During the Declared Disaster Emergency in the State of New York, a pharmacy can override edit 01642 or edit 0224, through reason for service code "Early Fill (ER) Overuse Precaution" in edit payer field 439-E4, for denials at the point of sale by using the following combination:
NCPDP FIELD 439-E4 REASON FOR SERVICE CODE AD = Additional Drug Needed
NCPDP FIELD 420-DK SUBMISSION CLARIFICATION CODE 07 = Medically Necessary - use to indicate the service is provided as a result of Immediate Urgent Care or Emergency.
In addition to using the above override codes, pharmacists are required to also document the Declared Disaster Emergency in the State of New York within the pharmacy´s processing system.
Contact the eMedNY Call Center at (800) 343-9000 for questions regarding billing.
For questions on this policy providers may e-mail the pharmacy mailbox at: ppno@health.ny.gov or call (518) 486-3209.
Medicaid Managed Care questions regarding policy and billing guidance for early fill should be directed to the enrollee´s Medicaid Managed Care plan.
