New York State Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance
Medicaid Managed Care
Medicaid Managed Care (MMC) plan policies and billing guidance for practitioner administered drugs can be found at the MMC Pharmacy Benefit Information Center. Select a plan and then the link to practitioner administered drug policy and billing guidance.
Practitioner administered drugs reimbursed by Medicaid fee-for-service pharmacy program for Managed Care Members.
| Drug/Drug Class Name | Clinical Criteria | Clinical Criteria Worksheet Fillable PDF* File |
|---|---|---|
| Betibeglogene autotemcel (Zynteglo®) | January 2024 | Zynteglo PDF |
MMC plans are required to comply with the requirements in the Medicaid Managed Care/Family Health Plus/ Human Immunodeficiency Virus (HIV) Special Needs Plan Model Contract Section 10-2, which can be found on the New York State Department of Health "Information for Health Care Providers" web page, and must ensure that covered services are provided in sufficient amount, duration and scope to reasonably be expected to achieve the purpose for which services are furnished.
