New York Medicaid Fee-For Service (FFS) Practitioner Administered Drug (PAD) Prior Authorization (PA) Program

• PAD Quick Reference Guide (PDF)

Quick Reference Guide

Beginning November 19, 2026, New York Medicaid Fee-For-Service (FFS) will require prior authorization (PA) for certain practitioner administered drugs (PADs) administered in office, clinic, or outpatient settings. Prescribers* will be required to obtain prior authorization before Medicaid will cover the cost of the drug because the Practitioner Administered Drug Program is changing from the "by report" manual pended claims process to a streamlined PA framework.

This change affects New York Medicaid Fee-For-Service members only.
Members enrolled in a Managed Care Organization (MCO) will continue to receive their medical benefits, including prior authorization, through their plan. Providers should review the Medicaid Managed Care Plan Information website for plan-specific requirements.

The PAD prior authorization system utilizes a sophisticated clinical editing system that uses pharmacy and medical claim data to rapidly approve claims that meet PA criteria. If the corresponding diagnosis, drug, or procedure code is already in the member's claim history, an approved PA can be generated without prescriber involvement. This approach streamlines the approval process, reduces administrative burdens, and improves claim reimbursement timelines.

*The "Prior Authorization Programs" section of the NYRx Medicaid Pharmacy Program Manual defines who can obtain prior authorization.

Prior Authorization

The prior authorization (PA) process will initially apply to certain drugs/classes for dates of service on or after November 19, 2026.

Botulinum Toxin Agents

• onabotulinumtoxinA (Botox®)
• abobotulinumtoxinA (Dysport®)
• rimabotulinumtoxinB (Myobloc®)
• incobotulinumtoxinA (Xeomin®)
• DaxibotulinumtoxinA-lanm (Daxxify®)

Infliximab Agents

• infliximab (Remicade®)
• infliximab-abda (Renflexis®)
• infliximab-axxq (Avsola®)
• infliximab-dyyb (Inflectra®)
• infliximab-dyyb (Zymfentra®)

Major Depression

• esketamine nasal spray (Spravato®)

Spinal Muscular Atrophy

• nusinersen (Spinraza®)

Duchenne Muscular Dystrophy (DMD)

• casimersen (Amondys 45)
• eteplirsen (Exondys 51)
• viltolarsen (Viltepso)
• golodirsen (Vyondys 53)

Over the coming months, additional PADs will be incorporated according to the guidance outlined in the Policies and Billing Guidance for Practitioner-Administered Drugs.

Verify if Prior Authorization is Required

Providers must obtain an approved PA before administering the drug to the member. All PA requests must be submitted using the National Drug Code (NDC) quantity, including any waste from single-use containers. The NDC PA quantity reflects the actual manufacturer-specific product amount (vial/each, milliliter, gram).

To determine if a PAD requires prior authorization, providers may:

• Check the clinical criteria table or Prior Authorization Program List.
• Alternatively, submit a real-time claim through the Electronic Provider Assisted Claim Entry System (ePACES) to check if a PAD requires prior authorization. If a claim is rejected with edit 00186 "Required Prior Approval (PA) for Procedure not Found" then the practitioner must obtain prior authorization. Refer to the ePACES Professional Real-Time Claim Reference Guide for further technical assistance.

How to Obtain Prior Authorization

Prior authorizations are processed 24 hours a day, 7 days a week. Practitioners can obtain a PA through any of the following options:

• Electronic (preferred method)
  • PAXpress (paxpress-nypa.acentra.com)
    • Use the same username and password as your ePACES account.
    • Applicable user types: primary administrator, supervisor, general user, or secondary administrator.
    • If an ePACES user type needs to be changed so that it can access PAXpress, please allow 24 hours for the update to process.
  • CoverMyMeds (www.covermymeds.health) - Check their quick guide about how to create an account and request PA.
• Fax the prior authorization form to 1-800-268-2990.
• Call the NYRx Clinical Call Center at Prime Therapeutics at 1 -877-309-9493, open 24 hours daily.

For support with obtaining a PA, contact the NYRx Education & Outreach Team at 1 -833-967-7310 or NYRxEO@primetherapeutics.com.

PAD Search Tool

The PAD Search Tool is a list of practitioner-administered drugs that can be billed to the medical benefit using an appropriate Healthcare Common Procedure Coding System (HCPCS) code and National Drug Code (NDC). The tool is intended to aid FFS providers with medical billing of drugs administered in an office or outpatient clinical setting.

*Please note, an update to this search tool is planned for early 2027 to provide a better user experience. Additional fields will be included to provide pricing details such as the Maximum Reimbursable Amount (MRA) and pricing source.

Electronic Claim Submission

Providers may submit professional claims electronically via ePACES or other methods accepted by eMedNY. Additional details and examples of billing for PADs are explained in the September 2026 Special Edition of the Medicaid Update. For help with claims and ePACES, check the ePACES Professional Real Time Claim Reference Guide and training videos, or contact the eMedNY Call Center at 1-800-343-9000.

Paper Claim Submission for Codes Listed "By Report"

There are certain drugs listed as "by report (BR)" on the Physician Manual Fee Schedule and Ordered Ambulatory Fee Schedule, such as cell and gene therapies. Providers will continue to submit paper claims for these drugs listed as "by report." More information is on the FFS policy and billing guidance website for practitioner administered drugs. For help with claims, contact the eMedNY Call Center at 1-800-343-9000.

Resources and Support

• Practitioner Administered Drug (PAD) Program
• Medicaid Update
  • March 2026 Reimbursement Change for New York State Medicaid Fee-for-Service Professional Drug Claims
  • September 2026 Practitioner Administered Drug Modernization - Part 2: Prior Authorization Changes for Select Drugs in New York State Medicaid Fee-for-Services
• PAD Search Tool
• PAD Top Edit Resource for Professional Claims
• Edit/Error Knowledge Base (EEKB) Search Tool

Email Notifications

To receive the latest updates about FFS policy and reimbursement for PADs, subscribe to the following email notification services:

• eMedNY LISTSERV® – There are mailing lists for specific provider types, including pharmacy, physician, nurse practitioner, and free standing or hospital based ordered ambulatory. Additionally, there are mailing lists for vendors and managed care plans.
• NYRx Education & Outreach Notification Service – Receive updates about prior authorization processes, clinical criteria, and other important news for NYRx stakeholders.

Team	Contact Information	Responsibilities
Office of Health Insurance Programs (OHIP) Division of Drug Policy and Rebate Management	Phone: (518) 486-3209 Email: NYRx@health.ny.gov Website: health.ny.gov/nyrx	Medicaid policy for pharmacy and medical drugs
eMedNY Call Center	Phone: (800) 343-9000 Website: emedny.org	FFS provider enrollment, billing, claims, and ePACES
NYRx Clinical Call Center	Phone: (877) 309-9493, Open 24 hours daily Fax: (800) 268-2990 Website: newyork.fhsc.com	Prior authorizations for NYRx
NYRx Education & Outreach Team	Phone: (833) 967-7310 Email: NYRxEO@primetherapeutics.com Website: newyork.fhsc.com	Liaison between stakeholders (such as prescribers, pharmacies, and managed care plans) and NYRx to support care coordination and provide materials, trainings, and timely communications regarding NYRx programs.