New York State Medicaid Update - January 2023 NYRx Pharmacy Benefit Transition Part Two: Special Edition Volume 39 - Number 1

In this issue …

Information for Pharmacies
Information for All Providers (Including Pharmacies)
Provider Enrollment
Appendix A: Resources
Appendix B: Member Fact Sheet

Information in gray boxes in this issue indicates material abridged but linked from the succinct interactive Portable Document Format (PDF) version.

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Effective April 1, 2023, New York State (NYS) Medicaid members enrolled in mainstream Medicaid Managed Care (MMC) Plans, Health and Recovery Plans (HARPs), and Human Immunodeficiency Virus-Special Needs Plans (HIV-SNPs) will receive their pharmacy benefits through the NYS Medicaid Pharmacy Program (NYRx) instead of through their MMC Plan. The pharmacy benefit transition to NYRx does not apply to NYS Medicaid members enrolled in Managed Long-Term Care (MLTC) Plans [e.g., MLTC, Programs of All-Inclusive Care for the Elderly (PACE), Medicaid Advantage Plus (MAP)], the Essential Plan (EP), or Child Health Plus (CHP). Transitioning the pharmacy benefit from MMC to NYRx will provide NYS with full visibility into prescription drug costs, allow centralization of the benefit, leverage negotiating power, and provide a uniform list of covered drugs with standardized utilization management protocols simplifying and streamlining the drug benefit for NYS Medicaid members and MMC enrollees. NYS Medicaid members have comprehensive drug coverage and equitable access to an extensive network of over 5,000 pharmacy providers. This guidance provides information in addition to what was provided in the October 2022 NYRx Pharmacy Benefit Transition - Part One Special Edition issue of the Medicaid Update.

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Information for Pharmacies

Effective April 1, 2023, pharmacies will need to bill NYRx using the Client Identification Number (CIN), which can be found on the NYS Medicaid Common Benefit Identification Card (CBIC) and on the MMC card of the enrollee. Each MMC Plan will implement point-of-service claim denial messaging that directs pharmacies to bill NYRx where applicable. In a future update, NYS Department of Health (DOH) will provide the claim denial messaging that will be used by MMC Plans, starting April 1, 2023.

When submitting NYRx claims to NYS Medicaid via the National Council for Prescription Drug Program (NCPDP) D.0 format, the Bank Identification Number (BIN) and Processor Control Number (PCN) are required. Specific details can be found in the October 2022 NYRx Pharmacy Benefit Transition - Part One Special Edition issue of the Medicaid Update. NYS Medicaid members may also contact the NYS Medicaid Consumer Helpline by calling (800) 541-2831 to obtain their CIN.

Member/Enrollee Identification Number - Client Identification Number
The MMC Plan Identification (ID) number card contains the Client Identification Number (CIN), which is unique to NYS Medicaid members and MMC enrollees and should be used to bill NYRx. The CIN is always represented in the following form at "XX00000X", and in some cases, the CIN may be embedded in the MMC Plan ID Number of the enrollee. The CIN can be found on both the Plan ID Card and NYS Medicaid CBIC of the NYS Medicaid member and MMC enrollee.

The chart below indicates the CIN format for each MMC Plan ID card. Card samples which identify the CIN location on the MMC Plan ID card can be found on the New York State Medicaid Managed Care (MMC) Pharmacy Benefit Information Center website.

Eligibility Determination
Pharmacists may conduct an eligibility check and/or obtain the CIN of the NYS Medicaid member and MMC enrollee, by using one of the methods in the chart below.

Identifying Transition Fills
As previously noted in the October 2022 NYRx Pharmacy Benefit Transition - Part One Special Edition issue of the Medicaid Update, a one-time "transition fill" will be allowed for non-preferred drugs and diabetic supplies. Pharmacists may work with the patient and contact their prescriber to either change the prescription to another drug or supply or obtain a prior authorization (PA) following the transition fill.

Transition fills will be identified in the eMedNY claim response using NCPDP field 548-6F, Approved Message Code, with code "005" - Claim paid under the plan's transition benefit period, otherwise claim would have rejected as PA is required.

Vaccines Administered by Pharmacists
As indicated in the Scope of Benefits document, vaccines that are administered by pharmacists are subject to the benefit transition and should be billed to NYRx. Policy and billing guidance for vaccines can be found within the New York State Medicaid Fee-for-Service Program Pharmacists as Immunizers Fact Sheet.

Policy and billing instructions for the administration for Coronavirus Disease 2019 (COVID-19) vaccines can be found under the "Both Medical and Pharmacy" tab of the NYS DOH "COVID-19 Guidance for Medicaid Providers - Coverage and Billing Guidance" web page.

Diabetic Supplies
The Scope of Benefits document provides a summary of diabetic supply items that are subject to the benefit transition. Diabetic diagnostics, continuous glucose monitors (CGM), glucose testing supplies, insulin syringes, disposable insulin pumps (Omnipod), and infusion supplies, will be transitioned to NYRx. NYRx covers all of these items, some of which are part of the Preferred Diabetic Supply Program (PDSP), located on the Magellan Health, Inc. Rx Management, LLC "Preferred Diabetic Supply Program" web page. NYS DOH will allow a one-time transition fill from April 1, 2023, through June 30, 2023, for non-preferred diabetic supplies that are not part of the PDSP and will honor PAs already provided by the MMC Plans.

Please note: Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Coverage and Billing Guidance will be provided in a subsequent Medicaid Pharmacy Benefit Transition - Part Three Special Edition issue of the Medicaid Update.

Brand Less than Generic Program
The Brand Less than Generic (BLTG) program is an initiative that promotes the use of certain multi-source brand name drugs when the cost of the brand name drug is less expensive than the generic equivalent. For a current listing of brand name drugs included in the BLTG program, providers can refer to the most recent program update on the Magellan Health, Inc. Rx Management, LLC "Brand Less Than Generic Program" web page.

Pharmacies will receive the following denial message when submitting claims for generic drugs in the BLTG program.

Denials for generics can be avoided by dispensing the brand name products. A new prescription is not required.

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Information for All Providers (Including Pharmacies)

Member Fact Sheet
Providers must use the Member Fact Sheet, found in Appendix B: Member Fact Sheet of this issue, to provide NYS Medicaid members and MMC enrollees with the resources and information they need regarding the benefit transition. A print-friendly version of the Member Fact Sheet is available on the NYS Member Dashboard homepage.

Prescription Limit Reminder– Duration and Refills
Prescriptions are valid and may be filled for up to one year from the date issued, with the exception of controlled substance prescription drugs. After the prescription expires, a new prescription will be required from the prescriber, even if refills remain on the original prescription.

Practitioner Administered Drugs
NYS DOH recognizes the need for certain drugs requiring administration by a practitioner to be available through the Medical and Pharmacy Benefit. Practitioner administered drugs (PADs) that are listed on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page may be billed directly to the NYRx under the pharmacy benefit. PADs obtained by the practitioner, may be billed as a medical claim to the MMC Plan of the enrollee.

NYS DOH analyzed PADs that are provided as a Pharmacy Benefit through MMC Plans. As a result of this analysis, NYS DOH has added certain PADs to the NYRx formulary. Please note: PADs dispensed as a Pharmacy Benefit must be delivered by the pharmacy directly to the site of administration. Additional information regarding pharmacy dispensing of PADs and delivery requirements can be found in the NYRx, The NY Medicaid Pharmacy Program - Pharmacy Manual Policy Guidelines, under the following sections: "Pharmacy Dispensing of Drugs That Require Administration by a Practitioner" and "Delivery". These requirements ensure proper storage and handling.

Over the Counter Drugs
There are some over the counter (OTC) drugs that may have been covered by MMC Plans that are not covered by NYRx; however, there are equivalent/comparable products available through NYRx. OTC drugs covered by the NYRX can be found on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page.

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Provider Enrollment

Providers servicing NYS Medicaid members and MMC enrollees must be enrolled by April 1, 2023.

How to Check Provider Enrollment Status
Providers can check their enrollment status by utilizing the tools available on the NYS DOH "Medicaid Enrolled Provider Lookup" web page. Providers can search by entering their NYS Medicaid provider ID or their NPI. Providers can use the table provided below to determine their current enrollment status and the corresponding action necessary as required from the "Medicaid Type" provided in the lookup tool. Providers who have submitted enrollment applications may check the status of their application in the "Medicaid Pending Provider Listing," which is updated weekly on the eMedNY "Medicaid Managed Care Network Provider Enrollment" web page.

Provider Type	"Medicaid Type"	Enrollment Status	Action Required
Pharmacy	Fee-for-service (FFS)	Enrolled (Qualified Billing Provider)	No action
	Managed Care Organization (MCO)	Not enrolled (MCO Credentialed as a non-billing provider)	Enroll with NYS Medicaid as a billing provider
	No result	Not enrolled	Enroll with NYS Medicaid as a billing provider
Practitioner/Prescriber	FFS	Enrolled (Qualified Billing Provider)	No action
	MCO	Not enrolled (MCO Credentialed as a non-billing provider)	Enroll with NYS Medicaid as a billing or an OPRA provider
	Ordering, Prescribing, Referring, Attending (OPRA)	Enrolled (Qualified non-billing provider)	No action
	No result	Not enrolled	Enroll with NYS Medicaid as billing provider or if eligible as a OPRA provider

Providers
Providers who prescribe drugs and supplies for NYS Medicaid members and/or MMC enrollees must be enrolled in NYS Medicaid as either an "Individual Billing" provider or as an OPRA provider for NYS Medicaid to cover the products. NYRx will pay for covered products and services for MMC enrollees when their prescriber is enrolled in NYRx.

Physicians, Nurse Practitioners, Physician Assistants, Podiatrists, Dentists, Optometrists, Audiologists, and Certified Nurse Midwives
Providers who wish to receive payment for covered NYS Medicaid services should apply as an "Individual Billing Medicaid". Information regarding how to enroll is available on the eMedNY "Provider Enrollment and Maintenance" web page. Providers who wish to enroll as an OPRA provider (non-billing) should alternatively enroll as a OPRA provider on the eMedNY "Provider Enrollment and Maintenance" web page.

Exceptions to the prescriber enrollment requirements for certain authorized prescribers are outlined in the Reminder: Pharmacy Billing Guidance Exceptions for Non-Enrolled Prescribers article published in the June 2022 issue of the Medicaid Update.

Pharmacies
NYRx will pay for covered products and services for MMC enrollees when their pharmacy is enrolled in NYRx. NYS DOH has updated the pharmacy enrollment policy, found within the NYRx, The NY Medicaid Pharmacy Program - Pharmacy Manual Policy Guidelines, which now allows enrollment of community-based pharmacies located in NYS or in the bordering states (Connecticut, Massachusetts, New Jersey, Pennsylvania and Vermont). The policy also provides a pathway to enrollment for pharmacies servicing MMC enrollees that are located outside of NYS and outside of the bordering states, or those that dispense drugs by exclusive arrangement.

DMEPOS Providers
The updated DMEPOS provider enrollment policy can be found within the New York State Medicaid Program Durable Medical Equipment, Prosthetic, Orthotic, and Supply Manual Policy Guidelines. DMEPOS providers that are located outside NYS may apply for enrollment if they meet the newly established guidelines. DMEPOS providers located in states bordering NYS may enroll if they support NYS Medicaid members in the common medical marketing area. Out-of-state DMEPOS manufacturers and mail order suppliers may also be considered on a case-by-case basis, as outlined in the New York State Medicaid Program Durable Medical Equipment, Prosthetic, Orthotic, and Supply Manual Policy Guidelines.

Information about the Durable Medical Equipment (DME) supplier application process can be found on the eMedNY "Provider Enrollment and Maintenance" web page for DME.

Physician Dispensers
For the current NYRx policy regarding physician dispensers, providers can refer to the Policy Clarification for Practitioner Dispensing article in the July 2022 issue of the Medicaid Update. Physicians who are already enrolled in NYS Medicaid as a Physician - Individual Billing Medicaid (Category of Service 0460) or Practitioner Group (Category of Service 0046 or 0090) may submit claims as described in the article above.

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Appendix A: Resources

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Appendix B: Member Fact Sheet

Member Fact Sheet
Providers must use the Member Fact Sheet, found in Appendix B: Member Fact Sheet of this issue, to provide NYS Medicaid members and MMC enrollees with the resources and information they need regarding the benefit transition. A print-friendly version of the Member Fact Sheet is available on the NYS Member Dashboard homepage.

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The Medicaid Update is a monthly publication of the New York State Department of Health.

Kathy Hochul
Governor
State of New York

James McDonald, M.D., M.P.H.
Acting Commissioner
New York State Department of Health

Amir Bassiri
Medicaid Director
Office of Health Insurance Programs