New York State Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance

Medicaid Fee-for-Service

New York State Medicaid fee-for-service (FFS) program policies and billing guidance for practitioner administered drugs (PADs) are available at:

The table below includes links to guidance for specific practitioner administered drugs or drug classes. Some drugs or drug classes have corresponding Practitioner Administered Drug Clinical Criteria Worksheets.

Providers will submit claims, including the Clinical Criteria Worksheet where applicable, using the Medical Assistance Health Insurance Claim Form New York State eMedNY-150003 with the following:

  • Healthcare Common Procedure Coding System (HCPCS) code for the drug.
  • The associated National Drug Code (NDC.)
  • A copy of the invoice dated within six months prior to the date of service and/or should include the expiration date of the drug.

New York State Medicaid General Professional Billing Guidelines document for claim submission guidance, including the address for submitting a claim form.

The address for submitting a claim form is:

eMedNY
P.O. Box 4601
Rensselaer, NY 12144-4601

Expedited/Priority Shipping:

327 Columbia Turnpike
ATTN: Box 4601
Rensselaer, NY 12144

Billing Questions, please contact the eMedNY Call Center at 1-800-343-9000.

Claim Submission

  • Claim processing may be delayed if the information submitted in this worksheet is illegible.
  • If the worksheet is left blank or information is missing the claim will be rejected for not enough documentation and reimbursement will be delayed.
  • A claim should not be submitted until the drug has been administered to the patient.
  • The manufacturer invoice showing the acquisition cost of the drug administered, including all discounts, rebates, and incentives must be submitted with the claim. The invoice must be dated within 6 months prior to the date of service and/or should include the expiration date of the drug, or it will be rejected for not enough documentation.
Linked Guidance
Drug or Drug Class Name Policy/Guidance Clinical Criteria Worksheet
Fillable PDF* File
AbobotulinumtoxinA (Dysport®) October 2022
November 2022		 Dysport (PDF)
Betibeglogene autotemcel (Zynteglo ®) January 2024 Zynteglo (PDF)
Chimeric Antigen Receptor (CAR) T-cell Therapy October 2021 N/A**
Duchenne Muscular Dystrophy (DMD) January 2022 DMD (PDF)
Elivaldogene autotemecel (Skysona®) December 2023 Skysona PDF
Esketamine (Spravato®) Nasal Spray August 2022 Spravato (PDF)
Etranacogene dezaparvovec-drlb (Hemgenix®) December 2023 Hemgenix PDF
Goserlin implant (Zoladex ®) March 2022 Zoladex (PDF)
IncobotulinumtoxinA (Xeomin ®) October 2022
November 2022		 Xeomin (PDF)
Infliximab products October 2022
March 2023		 Infliximab (PDF)
Nusinersen (Spinraza®) March 2023 Spinraza (PDF)
OnabotulinumtoxinA (Botox®) October 2022
November 2022		 Botox (PDF)
Onasemenogene aberparvovec-xioi (Zolgensma ®) November 2019 Zolgensma (PDF)
RimabotulinumtoxinB (Myobloc ®) October 2022
November 2022		 Myobloc (PDF)
Vedolizumab (Entyvio®) October 2022
March 2023		 Entyvio (PDF)
Viscosupplementation with Hyaluronan or Derivative April 2022 Viscosupplementation (PDF)
Voretigine neparvovec-rzyl (Luxturna™) Luxturna (PDF) N/A**

* PDF - Portable Document Format
** N/A - Not Applicable