New York State (NYS) Medicaid fee-for-service (FFS) is continuing its phased modernization of practitioner-administered drug (PAD) reimbursement and clinical review processes. With the program expanding to oversee both pharmacy and medical drug benefits, it is adopting a new name, NYRx, the NYS Medicaid Drug program. This change signals a broader transformation in how NYS Medicaid manages the NYS Medicaid FFS drug benefits. By moving PAD claims from a post-submission manual review to a real-time, criteria-based process, the program aims to ensure clinical appropriateness and accelerate provider reimbursement.

As announced in the March 2026 Special Edition issue of the Medicaid Update, beginning November 19, 2026, NYS Department of Health will implement changes to the pricing benchmarks used to determine the maximum reimbursable amount for drugs provided and claimed separately by medical practitioners. Additionally, NYS Department of Health will implement an automated clinical editing prior authorization (PA) process for select PADs. For providers, these changes may reduce administrative burdens and improve claim reimbursement timelines.

PA Process for PADs

Prescribers will be required to obtain PA for these drugs/drug categories before NYS Medicaid will cover the cost of the drug. The change moves these drugs from the current "By Report" ("BR") manual pended claims process to a streamlined PA framework. The program utilizes a sophisticated clinical editing system that leverages pharmacy and medical claim data to rapidly approve claims that meet PA criteria. If the corresponding diagnosis, drug, or procedure code is already present in the claim history of the NYS Medicaid member, an approved PA can be generated without additional prescriber involvement.

Further information regarding medical coding can be found in the Importance of Medical Coding on Practitioner Drug Claims article published in the September 2023 issue of the Medicaid Update.

PADs Requiring PA

The PA process will initially apply to select drugs within certain drug classes. The initial drug list, effective November 19, 2026, is as follows:

• Botulinum toxin agents:
  • onabotulinumtoxinA (Botox®)
  • abobotulinumtoxinA (Dysport®)
  • rimabotulinumtoxinB (Myobloc®)
  • incobotulinumtoxinA (Xeomin®)
  • daxibotulinutoxinA (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 on the NYS Department of Health "Policies and Billing Guidance for Practitioner Administered Drugs" web page.

Affected Category of Service Types and Billing Transaction

PA for select PADs apply for the following categories of service (COS) that are submitted via Professional ASC X12, 837 Health Care claim transactions:

• Free Standing or Hospital Based Ordered Ambulatory (COS "0163" for clinic-based, COS "0282" for hospital-based)
• Physician (COS "0460")
• Nurse practitioner (COS "0469")
• Midwife (COS "0525")
• Podiatry services (COS "0500")

Please note: Drugs administered in a facility or inpatient setting will continue to be reimbursed at the posted facility rates. This includes, but is not limited to, All Patient Refined-Diagnosis Related Groups (APR-DRG) and Ambulatory Patient Groups (APG).

What Providers Need to Do

Providers must ensure an approved PA is obtained prior to the drug administration. When requesting PA, providers must submit the total quantity of National Drug Code (NDC) units. This should represent the amount (volume) of drug administered to the patient.

To determine if a PAD requires PA, providers may:

• consult the NYS Department of Health "Policies and Billing Guidance for Practitioner Administered Drugs" web page; and/or
• verify via ePACES by submitting a real-time claim through Electronic Point of Service Claims (ePACES). If a PA is required, the claim will return Edit 00186: Procedure Requires PA(see Table 1) on the remittance statement of the provider. Providers should refer to the ePACES Professional Real-Time Claim Reference Guide, for further technical assistance.

Table 1

For information and assistance with other commonly rejected claim edits, providers should refer to the links below:

• New York Medicaid Fee-For-Service (FFS) Practitioner Administered Drugs (PADs): Top Edit Resource for Professional Claims
• eMedNY "Edit/Error Knowledge Base (EEKB) Search Tool" web page

How to Obtain Prior Authorization (Available 24/7)

Providers can obtain PAs through the following modalities:

• Electronic (preferred method), which can be submitted through:
  • PAXpress™
    • PAXpress™ requires an active ePACES account (same ePACES username and password).
    • PAXpress™ is only applicable to the following user types: Primary admin, supervisor, general user, or secondary admin.
    • If an ePACES user type needs to be changed to access PAXpress™, the user type should allow 24 hours for the update to process.
    • User types should refer to the eMedNY PAXpress User Manual.

• CoverMyMeds®
  • Providers should review the CoverMyMeds® "Quick Guide to CoverMyMeds Prior Authorization Requests" web page, to become familiar with the process.
  • Provider should visit the CoverMyMeds® Log In web page, to create an account, complete a profile, and explore the platform.
  • Providers must ensure that all information in your profile is accurate. It is also recommended that if an authorized agent is utilized for electronic PA submissions, providers must ensure their profiles are validated with the prescriber NPI.
• Telephone: Contact the Prime Therapeutics Call Center at (877) 309-9493.
• Fax: Send completed PA forms to (800) 268-2990.

NDC PA Requirements

As a reminder, Healthcare Common Procedure Coding System (HCPCS) codes represent the service/drug procedure (e.g., J-codes, Q-codes) and are billed in units based on the dosage description defined by the Centers for Medicare and Medicaid Services (CMS), while the NDC quantity reflects the actual manufacturer-specific product amount (vial/each, milliliter, gram). HCPCS units are for reimbursement based on standardized billing units, whereas NDC quantity is for tracking inventory and accurate payment, often requiring conversion from milligrams (MG) to milliliters (ML), units (UN), or grams (GR). While both units are required for proper claim submission, all PA requests must be submitted using the NDC quantity, including any waste from single use containers.

For additional information on PA submission of the NDC quantity, providers should refer to these additional resources:

• eMedNY PAXpress User Manual
• CoverMyMeds® "Quick Guide to CoverMyMeds Prior Authorization Requests" web page

PAD Waste

When requesting a PA, the provider must enter the total quantity of NDC, including any waste from single-use containers. As a reminder, NYS Medicaid FFS will reimburse providers for the unused, appropriately discarded portion of a drug or biologic from a single-use vial or single-use package that is not administered to the patient. Drug waste from multi-use vials/packages will not be reimbursed.

PAD Search Tool

The PAD Search Tool lists covered HCPCS codes for providers billing drugs separately and includes valid NDC/HCPCS combinations. The NDC/HCPCS must be listed accordingly on the crosswalk to be a covered benefit. The tool also aims to assist providers in utilizing the correct HCPCS units and NDC quantity, as required by the 2005 Federal Deficit Reduction Act. Information related to both the NDC package size and HCPCS billing unit are displayed. Results can be expanded to view additional details of the HCPCS code.

Providers should utilize the red "SEARCH TIPS" tab on the left side of the eMedNY "Practitioner Administered Drug (PAD) Search Tool" web page, for definitions and further descriptions. Providers should refer to the Practitioner Administered Drug Search Tool Now Available on the eMedNY Website article published in the March 2024 issue of the Medicaid Update, for detailed instructions regarding the PAD Search Tool and search results.

Please note: Drugs requiring PA will display "Prior Approval Required" under the "PA Required Code" header after November 19, 2026. Select drugs will continue to require manual review. 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 and pricing source.

Key Differences in Calculating HCPCS Units and NDC Quantity Amounts

• HCPCS Units: Based on total dosage administered divided by the descriptor in the J-code description. This measure is specific to the HCPCS code for the drug. This is defined by the "HCPCS Code Dosage Description" within the PAD Search Tool.
• NDC Quantity: Based on the unit of measure for that specific drug (e.g., ML for liquid, UN for vials, GR for grams). This is defined by the "Billing Unit Type" value within the PAD Search Tool. Please note: This measure is specific to each NDC.

Billing Examples

• Drug: Botox® 200-unit vial
  • HCPCS billing units:
    • "J0585": Injection, onabotulinumtoxinA
    • One HCPCS unit = one unit of Botox®
      • 150 units administered to a patient with chronic migraines = 150 HCPCS units
• NDC billing quantity:
  • NDC 00023-3921-02: Botox® 200-unit vial
  • One NDC quantity = one each (vial) = 200 units of Botox®
  • 150 units administered to a patient with chronic migraines = 0.75 NDC quantity*
    *When completing PA requests, include total units, including waste in the request by rounding up to the nearest unit. Providers must continue to bill for reimbursement as previously advised.

Example Electronic Claim

Drug: Remicade® 100 mg Vial

• HCPCS billing units:
• "J1745": Injection, Infliximab, Excludes Biosimilar, 10 mg
• One HCPCS Unit = 10 mg of Remicade®
  • 400 mg administered to a patient = 40 HCPCS units
• NDC billing quantity:
  • NDC 57894-0030-01: Remicade® 100 mg Vial
  • One NDC quantity = one vial = 100mg of Remicade
    • 400 mg administered to a patient = four NDC quantity

Example Electronic Claim

Paper Billing for Unclassified Codes Listed "BR"

As a reminder, there are certain drugs on the NYS Medicaid Physician Drug and Drug Administration Services Fee Schedule and on the NYS Medicaid Ordered Ambulatory Fee Schedule, that are designated "BR", such as cell and gene therapies, or PADs that are newly Food and Drug Administration-approved or have no assigned HCPCS code. These drugs will continue to be billed via paper claim on a Medical Assistance Health Insurance Claim Form (eMedNY 150003 form). Manufacturer invoices within six months of purchase are required showing the acquisition cost of the drug administered, including all discounts, rebates, and incentives, per program policy. In addition, providers are required to report the NDC and quantity. Please note: This quantity may be different from the number of billed HCPCS units.

Questions and Additional Information:

• For PAXpress™ or ePACES claims and technical support, providers should contact the eMedNY Call Center at (800) 343-9000. Provider training videos are located on the eMedNY "Provider Training Videos" web page.
• To access PAXpress™, providers should refer to the PAXpress™ website.
• Providers should refer to the eMedNY PAXpress User Manual, which is designed for providers to request a PA from NYS Medicaid.
• For member eligibility information, providers should verify via ePACES or the Telephone Verification System at (800) 997-1111.
• For NYS Medicaid FFS manuals, providers should refer to the eMedNY "Provider Manuals" web page.
• For Managed Care Plan information, providers should refer to the NYS Department of Health "Medicaid Managed Care Plan Information" web page.
• For policy and billing guidance for PADs, providers should refer to the NYS Department of Health "Policies and Billing Guidance for Practitioner Administered Drugs" web page.
• NYS Medicaid FFS drug policy questions should be directed to the Office of Health Insurance Programs Division of Program Development and Management by telephone at (518) 486-3209 or by email at NYRx@health.ny.gov.