Transition of the Pharmacy Benefit from Managed Care (MC) to Medicaid NYRx Pharmacy Program
- FAQs also available in Portable Document Format (PDF)
Frequently Asked Questions (FAQs)
Published: October 1, 2024
General
FAQ 168 Has the Pharmacy Benefit Transition happened?
Published: May 12, 2023
Yes, the pharmacy benefit transitioned to NYRx on April 1, 2023
FAQ 001 What is the main objective of the transition of the pharmacy benefit from Managed Care (MC) to the Medicaid Pharmacy program, NYRx?
Updated: July 8, 2022
Transitioning pharmacy services from MC to NYRx will, among other things:
- Provide the State with full visibility into prescription drug costs.
- Centralize and leverage negotiation power.
- Provide a single drug formulary with standardized utilization management protocols.
- Address the growth of the 340B program and associated reductions in State rebate revenue.
FAQ 002 Will the transition be a phased implementation or implemented all at once?
Updated: May 12, 2023
NYS DOH implemented the transition all at once, effective April 1, 2023.
FAQ 004 Will rebates increase as a result of the transition of the benefit from Managed Care (MC) to Medicaid NYRx Pharmacy program?
Updated: July 8, 2022
Yes, NYS DOH anticipates an increase in both federal and state supplemental rebates due to the transition to a single standardized formulary, which will allow the State to optimize federal rebates and increase the State's leverage to negotiate supplemental rebates with manufacturers.
FAQ 006 Has NYS DOH considered other ways or contingency plans to achieve State savings if the pharmacy benefit transition does not achieve anticipated savings?
Updated: July 8, 2022
NYS DOH believes the transition of the pharmacy benefit from Managed Care (MC) to the Medicaid NYRx Pharmacy program is in the best interest of the Medicaid program and Medicaid beneficiaries, and that it will achieve the objectives outlined in FAQ 001 . As such, NYS DOH is confident that the pharmacy transition will generate savings.
FAQ 037 Has NYS DOH consulted with other states such as California and Michigan for insight regarding their transition of the pharmacy benefit from Managed Care (MC) to Fee-For-Service (FFS)?
Updated: July 8, 2022
Yes, DOH has consulted for and with several other states, including California and Michigan, regarding their transition of the pharmacy benefit from Managed Care to Fee-For-Service. In addition, DOH participated on a multi-state working group to discuss implementation strategies related to the pharmacy benefit transition and garnered insight from various states specific to the transition. These conversations and activities have informed and continue to guide DOH's approach in implementation of the transition.
FAQ 038 How will the transition of the Medicaid pharmacy benefit from Managed Care (MC) to Medicaid NYRx Pharmacy program be communicated to Medicaid Members and Prescribers? Will Managed Care Plans (MCP) and NYS DOH be reaching out to Medicaid Members and Prescribers?
Updated: May 12, 2023
Communication about the transition of the pharmacy benefit to NYRx has been done by both NYS DOH and the MCPs and has been accomplished through a variety of methods including letters and Medicaid Update articles. Additional information regarding these communications and their timing can be found within the Transition and Communications Activities Timeline document.
FAQ 062 As part of the pharmacy transition, will NYS DOH engage in exclusive contracts with any particular specialty pharmacy providers or specialty pharmacy provider networks?
Updated: July 8, 2022
No, NYS DOH does not intend to engage in exclusive contracts with particular specialty pharmacy providers, as part of the pharmacy benefit transition.
FAQ 064 In response to the pharmacy transition, how and what is the best way for a company to request or signal interest in negotiating around certain product(s) with NYS DOH?
Updated: October 1, 2024
NY State participates in the National Medicaid Pooling Initiative (NMPI) to access supplemental rebates for drugs included in the Preferred Drug Program.
Questions regarding the NMPI bid solicitation may be sent to: NYPDPnotices@primetherapeutics.com.
Questions regarding the Preferred Diabetic Supply Program may be submitted via the contact form.
Questions regarding any other products subject to the carve-out may be sent to: NYPDPnotices@primetherapeutics.com.
FAQ 115 What is the difference between NYS Medicaid Fee-For-Service and the NYRx pharmacy program?
Published: November 8, 2022
Medicaid Fee-For-Service includes all benefits. NYRx is the new name for the pharmacy benefit under the New York State Medicaid Program. Nothing has changed with the Medicaid pharmacy program except the name.
NYRx is:
- Easily recognizable
- Clearly identifies the Medicaid Pharmacy Program
- Reduces stigma associated with Medicaid
1115 Medicaid Redesign Team (MRT) Waiver
FAQ 007 What is the 1115 Waiver amendment and how does it affect the pharmacy benefit?
Updated: June 20, 2023
The New York State´s Medicaid Section 1115 MRT Waiver (formerly known as the Partnership Plan) is the current authority under which the pharmacy benefit is delivered by the Managed Care Plans (MCPs). Since the pharmacy benefit has transitioned to the Medicaid NYRx Pharmacy program, the 1115 MRT Waiver must be amended accordingly to support the transition.
340B
FAQ 012 How will 340B Hemophilia Treatment Centers be impacted by the pharmacy benefit transition?
Updated: June 20, 2023
Having transitioned to the Medicaid NYRx Pharmacy program on April 1, 2023, Hemophilia Treatment Centers will bill the NYRx program for covered drugs and products that are included in the outpatient pharmacy program. This includes outpatient prescription drugs and clotting factor. More detail regarding the drugs and other products that are included in the outpatient pharmacy benefit can be found at the following link.
FAQ 014 Is there a current 340B formulary? When the pharmacy benefit is transitioned to the Medicaid Pharmacy program, NYRx, will 340B providers be able to bill a "340B claim" to the NYRx program for Managed Care (MC) members?
Updated: June 20, 2023
There is currently no separate 340B formulary. Essentially, the 340B Covered Entity determines whether they will use 340B drugs for Medicaid members. Effective April 1, 2023, the pharmacy benefit has transitioned to NYRX, in which MC members will access their pharmacy benefit through the NYRx program and providers submitting 340B claims for MC members, will follow Medicaid NYRx Pharmacy program billing policies for 340B claims.
FAQ 015 Will the Fee-For-Service (FFS) claim submission requirements for 340B drugs (i.e., submitting the UD modifier) change as a result of the pharmacy benefit transition?
Updated: June 20, 2023
No, there have not been any changes in the way in which 340B claims will be submitted now that the pharmacy benefit has transitioned from Managed Care (MC) to NYRx. If there are changes, they will be communicated to providers via a Medicaid Update article. For information on how to bill 340B claims please see the 2021 November Medicaid Update.
FAQ 016 Will servicing providers who are prescribing medications for members who are either Medicare or dually eligible be able to use the 340B program for Medicare?
Updated: July 8, 2022
The Pharmacy Benefit Transition from Managed Care (MC) to the Medicaid NYRx Pharmacy program will have no impact to providers ability to use the 340B program for Medicare or dually eligible beneficiaries. Information regarding the Health Resources and Services Administration (HRSA) requirements for Covered Entities can be found by accessing the following link.
Information regarding Medicaid FFS 340B claim submission requirements, including submission requirements for dually eligible members can be found at the following link.
FAQ 041 Where can information be found regarding 340B Advisory Workgroup meeting discussions?
Updated: July 8, 2022
Presentation copies for 340B Advisory Group meetings are posted on the NYS DOH MRT II NY Medicaid Pharmacy Program (NYRx) website under the "Stakeholder Engagement" section and are organized by date.
FAQ 042 Has NYS DOH reviewed and/or considered alternative 340B models, such as the Texas model?
Published: July 8, 2022
Yes, NYS DOH has reviewed and considered several alternative 340B models, including the Texas Shared Savings model. After careful consideration of these models, NYS DOH believes that the pharmacy transition, including the reinvestment of 340B savings to Covered Entities, achieves the policy goals that are in the best interest of the Medicaid program and its beneficiaries. These policy goals are outlined in slide # 4 of the August 17th, 2020 All Stakeholder meeting.
FAQ 082 Will the Pharmacy Benefit Transition result in moving contracted pharmacies out of clinics? If so, how will patient access be impacted?
Updated: July 8, 2022
No, the Pharmacy Benefit Transition will not result in moving contracted pharmacies out of clinics. Such decisions are left to 340B Covered Entities. If a clinic makes the decision to move their contracted pharmacies out of their clinics, patients will continue to have access to needed medications at another Medicaid enrolled pharmacy. If a Covered Entity does choose to move their contracted pharmacy out of their clinics, NYS DOH would not anticipate any negative impacts to Medicaid members accessing their medications.
FAQ 127 Will New York State require all 340B covered entities to carve-in Medicaid for 340B at entity-owned pharmacies and for clinic/physician administered drugs?
Published: December 14, 2022
The Pharmacy Benefit Transition does not require 340B entities to carve in pharmacy/clinic/physician administered Medicaid claims at either the Covered Entity or its contract pharmacies.
Managed Care Plans (MCPs)
FAQ 017 What health plans does the pharmacy benefit transition apply to? Will the pharmacy benefit transition impact dual eligible members that have Medicare Advantage and Medicaid? Does the pharmacy benefit transition apply to Managed Long-Term Care plans? Does the pharmacy benefit transition apply to CHP?
Updated: June 20, 2023
The Medicaid NYRx Pharmacy Benefit Transition does not apply to Managed Long-Term Care plans (e.g., PACE, MAP, Partial MLTC, MLTC), the Essential Plan, or Child Health Plus (CHP).
The NYRx Medicaid Pharmacy Benefit Transition applies to all mainstream Managed Care Plans (MCPs), including Health and Recovery (HARP) and HIV-Special Needs (SNP) plans. More information can be found on slide 3 of the Transition of the Pharmacy Benefit from Managed Care to Fee-for-Service (FFS): Implementation Update & Strategy presentation.
FAQ 018 How will the role of the Managed Care Plans (MCPs) change after the pharmacy benefit is transitioned into Medicaid NYRx Pharmacy program?
Published: August 4, 2020
MCPs will continue to be responsible for maintaining all activities necessary for their enrolled members' care coordination and claims payment for non-outpatient pharmacy services and related activities, consistent with contractual obligations. The MCPs will determine the personnel and resources that they need in order to continue to perform these functions.
Information regarding MCPs and NYS DOH roles can be found at the following link. NYS DOH will work closely with the MCPs to provide access to pharmacy data that is necessary to support the activities for which they are responsible.
FAQ 116 Following the pharmacy benefit transition, will there still be Medicaid Managed Care Plans (MCPs) in New York State Medicaid?
Published: November 8, 2022
The pharmacy benefit transition only applies to the Medicaid pharmacy benefit. Managed Care Plans (MCPs) will continue to be responsible for providing other benefits, such as medical benefits, etc.
FAQ 019 How will the pharmacy benefit transition impact Managed Care (MC) rate setting?
Updated: July 8, 2022
NYS DOH and its actuary will adjust MC rates to account for the pharmacy benefit being transitioned to the Fee-For-Service (FFS) program. Per federal regulations, all Medicaid MC rates are required to be actuarially sound.
FAQ 020 How will the pharmacy benefit transition impact the Value Based Payment (VBP) arrangements that Managed Care Plans (MCPs) currently have with providers?
Updated: July 8, 2022
NYS DOH discussed the topic of VBP arrangements with MCPs and subject matter experts during multiple Technical Workgroup meetings. MCPs were asked to review the data file format along with other data sharing and prior authorization information and consider whether these provide the data and information needed to support VBP arrangements.
Based on this evaluation, NYS DOH does not view the transition of the Pharmacy Benefit to Medicaid Fee-for-Service (FFS) as a barrier for existing or future VBP arrangements. NYS DOH will be delivering data to the plans in the form of a daily claims file (please refer to FAQ 056 and FAQ 104), as well as a set of on-demand reports (please refer to the to the Transition and Communication Activities Timeline). These reports will provide for timely access to critical data and ensure that existing VBP arrangements between MCPs and providers continue post transition.
FAQ 021 How will Managed Care Plans (MCPs) be impacted by the pharmacy benefit transition in relation to HEDIS/QARR measures?
Updated: July 8, 2022
NYS DOH discussed the topic of HEDIS/QARR measures with MCPs and subject matter experts during multiple Technical Workgroup meetings. MCPs were asked to review the data file format along with other data sharing and prior authorization information and consider whether these provide the data and information needed to support reporting HEDIS/QARR.
It was determined that the current QARR measures were largely in place prior to the 2011 Carve-In - current measures can be found in the eQARR online report. More than 50% of total QARR measures use pharmacy data in the measurement calculation (e.g., denominator, numerator, or both) - pharmacy data will continue to be important. It is NYS DOH's assumption that all quality measures will continue to be calculated and reported by health plans as a part of QARR reporting. It is also NYS DOH's assumption that plans will need pharmacy data in order to report out on QARR measures. The data sharing between NYS DOH and MCPs will support continued reporting on measures.
Lastly, NYS DOH provided responses to the MCPs to support plans in answering Table 1.4 Ancillary Provider Data in Section 1: Medical Services and Processing of the HEDIS Roadmap. For more information regarding QARR reporting please refer to FAQ 070.
FAQ 022 How will the State transition the current pharmacy related activities that are being done by the Managed Care Plans (MCPs) (e.g. quarterly formulary submissions, claims run out, etc.)?
Updated: May 14, 2021
The Transition and Communication Activities Timeline has been developed and reviewed collaboratively with the Managed Care Plans at recurring Technical Workgroup meetings.
FAQ 046 What updates to "administrative expenses" can Managed Care Plans (MCPs) expect post-pharmacy benefit transition to account for data management and care management activities related to pharmacy coverage that will remain with MCPs?
Updated: July 8, 2022
In accordance with the standard rate development and rate setting process, Managed Care Plans can expect to be provided with updates from the Division of Finance and Rate Setting (DFRS) and the State's Actuary regarding how the administrative cost portion of the capitated rate will be affected by the pharmacy benefit transition. As addressed in FAQ 116 Following the pharmacy benefit transition, will there still be Medicaid Managed Care Plans (MCPs) in New York State Medicaid?
Published: November 8, 2022
The pharmacy benefit transition only applies to the Medicaid pharmacy benefit. Managed Care Plans (MCPs) will continue to be responsible for providing other benefits, such as medical benefits, etc.
FAQ 019, federal regulations require that all Medicaid MC rates be actuarially sound.
FAQ 047 How will the pharmacy benefit transition impact Critical Risk Groups (CRG)/ risk score methodology or weights? Will new CRG rules be released? If so, when?
Updated: July 8, 2022
The pharmacy benefit transition will not impact the critical risk groups (CRGs) methodology or process. The current risk adjustment methodology utilizes both Managed Care (MC) encounters and Fee-For-Service (FFS) claims as grouper inputs.
FAQ 048 How will the upcoming changes affect medical benefit drugs? Will Managed Care Plans (MCP) set policy for the utilization of medical benefit drugs, or will NYS DOH establish a utilization management policy for the MCPs to follow? Will Managed Care Plans (MCPs) utilize their own formulary or the Medicaid NYRx Pharmacy formulary for practitioner-administered drugs that are currently billed to MCPs?
Updated: July 8, 2022
The transition will not change the MCPs' responsibility for developing coverage and billing policies for practitioner administered drugs for their members, as referenced in the Scope of Benefits document. MCPs will continue to make practitioner administered drugs available when billed as a medical or institutional claim.
FAQ 069 How will the Restricted Recipient Program (RRP) be impacted by the pharmacy benefit transition? Will the RRP be transitioned to the Medicaid NYRx Pharmacy program or will Managed Care Plans (MCPs) receive modified procedures to accommodate the bifurcation of the medical and pharmacy benefit?
Updated: July 8, 2022
NYS DOH and the Office of the Medicaid Inspector General (OMIG) will work with the MCPs to develop and implement modified procedures that support the Restricted Recipient Program.
FAQ 070 Will pharmacy data be counted as administrative or supplemental data for use of QARR reporting after the pharmacy benefit transition?
Updated: July 8, 2022
The pharmacy data file that will be sent from NYS DOH would be considered administrative data for use of QARR reporting. NCQA will consider it as encounter data for the purposes of reporting. Please note that the data file is currently undergoing design through collaboration with the Managed Care Plans (MCPs).
FAQ 071 Regarding an NCQA audit response, prior to the transition Managed Care Plans (MCPs) were asked to provide the record of medication dispensing as part of HEDIS and QARR reporting. Would MCPs still be expected to provide that information even though the plan did not pay for the survey?
Updated: July 8, 2022
The MCP should inquire with the NCQA health plan auditor requesting that information.
FAQ 074 How will Durable Medical Equipment (DME) supplies with approved authorization be impacted after April 1, 2023? Will Managed Care Plans (MCPs) be required to send a notice advising the member that the rental is stopped as a result of it being a Fee-For-Service (FFS) item?
Updated: July 8, 2022
DME supplies found within the Durable Medical Equipment, Prosthetics, Orthotics, Supplies and Procedure Codes and Coverage Guidelines will remain the responsibility of the MCPs and therefore should not be impacted for discontinuation of a Prior Authorization (PA) or rental with respect to the pharmacy benefit transition. More guidance will be forthcoming regarding DME supplies found within the Pharmacy Procedures & Supply Codes as review and analysis is in progress.
FAQ 090 Following the Pharmacy Benefit Transition it is anticipated that the pen needle and syringe product class will not be managed by NY Medicaid. As a result of this, would the Managed Care Plans (MCPs) still be able to implement their own controls/contracts in this category (since they typically cover it under pharmacy)?
Updated: July 8, 2022
Syringes and needles are subject to the Pharmacy Benefit Transition and therefore will be covered under the Medicaid NYRx Pharmacy Program. More information regarding needles and syringe products can be found on page 17 within Section 4.2 Enteral And Parenteral Therapy of the Pharmacy Procedures & Supply Codes manual.
FAQ 145 Following the transition, what is the expectation of Medicaid Managed Care Plans (MCPs) to monitor Fraud, Waste, and Abuse? What is the expectation of MCPs related to care coordination?
Updated: May 12, 2023
Medicaid Managed Care Plans (MCPs) must continue to comply with federal and State requirements to monitor and report all cases of potential fraud, waste, and abuse. The MCP administers the medical benefits and, as of 4/1/23, the MCP will receive the pharmacy daily claims file to allow for a complete medical claim review. If an MCP suspects fraud, waste, or abuse, they should report that to the Office of the Medicaid Inspector General (OMIG).
Additional information can be found on the Office of the Medicaid Inspector General's Medicaid Managed Care Fraud, Waste, and Abuse Prevention Programs Guidance and Forms page.
In addition, MCPs are required to provide comprehensive care management and care coordination. This includes but is not limited to evaluation of medication adherence, medical appointments, initial filling of medications for targeted disease states, etc.
As of 4/1/23, the MCPs began receiving a daily claims file of pharmacy claims to allow for a completion of the above activities.
Formulary Management and Drug Utilization Review (DUR)
FAQ 023 What formulary will be used when the pharmacy benefit is transitioned to the Medicaid NYRx Pharmacy program and how will it be updated? Will the State use the current Medicaid NYRx Pharmacy reimbursement methodology?
Updated: June 20, 2023
As the pharmacy benefit is transitioned to the NYRx program effective April 1, 2023, the Medicaid Pharmacy List of Reimbursable Drugs will continue to be used and updated as it is today. The full list of reimbursable drugs may be viewed online or downloaded. Likewise, the Medicaid NYRx Pharmacy reimbursement methodology will be used.
FAQ 105 Will there be any changes to the Single Statewide Medication Assisted Treatment (MAT) formulary following the transition?
Published: October 12, 2022
There will not be any changes to the coverage criteria for MAT therapy with this transition and MAT therapy will continue to be covered by NYRx for all Medicaid enrollees. Prior authorization is not required for medications used for the treatment of substance use disorder when prescribed according to generally accepted national professional guidelines for the treatment of a substance use disorder.
FAQ 024 How will the pharmacy benefit transition impact the way in which the DUR Board is operated?
Updated: July 8, 2022
The transition will not change the way in which the DUR Board operates. Information regarding the DUR Board can be found at the following link.
FAQ 083 Is NYS DOH actively negotiating with companies that have product(s) with a large percentage of claims within Medicaid Managed Care (MC) but not the Medicaid NYRx Pharmacy program? Likewise, is NYS DOH evaluating potential products to add to the NYRx formulary that have a large number of claims in Medicaid MC and the product is non-preferred by NYRx?
Published: November 5, 2020
NYS DOH has a standard process that is utilized for the Medicaid NYRx Pharmacy Program to collect bids from manufacturers under the Preferred Drug Program (PDP) as well as the Preferred Diabetic Supply Program (PDSP). It is the intent of NYS DOH to continue to utilize that process consistent with how it has been handled in NYRx.
As referenced in the October 19th, 2020 All Stakeholder Presentation, NYS DOH analyzed managed care claims by program area to inform transition strategy. Slides 12 &13 of this presentation provide details regarding this analysis and the transition strategy that will be used to ensure continued access to medications.
FAQ 179 If the applicable clinical criteria have been met, and there are multiple preferred drugs listed on the NYRx Preferred Drug List (PDL), how many preferred drugs must be tried before a non-preferred drug can be prescribed without requiring prior authorization?
Published: July 26, 2023
The Drug Utilization Review Board (DURB) provides recommendations for preferred drugs based on FDA labeling and current clinical practice guidelines. Trial of one preferred drug, within a recent timeframe, is usually sufficient unless otherwise indicated on the PDL.
FAQ 180 Is there any change to the NYRx policy of not allowing autofill for members?
Published: July 26, 2023
Automatic refill programs offered by pharmacies are not an option for NYS Medicaid members. Automatic refilling of prescriptions/orders for prescription drugs, over-the-counter products, medical surgical supplies, and enteral products are not allowed under New York State Medicaid. This policy does not preclude other adherence programs. All laws, regulations and policies must be followed.
The following Refill Requests are allowed:
- Requests for a refill by a Medicaid member or designated caregiver who initiates the request for a refill to the pharmacy.
- Provider directly initiates refill by contacting a Medicaid member to determine if a refill is necessary, by phone, or electronic means (e.g., text message). Documentation of the need for each refill shall be maintained in the patient record. The documentation must include the date and time of member contact, the Medicaid member's or designated caregiver's name with response, and the name of the pharmacy staff member who contacted the member or caregiver (if by phone), or electronic method. The documentation must be available for audit purposes. Compliance with HIPAA privacy guidelines is mandatory.
FAQ 181 What is the NYRx policy for lost/stolen medications?
Published: July 26, 2023
If a Medicaid member has experienced a loss or theft of medication, pharmacy providers should instruct members to contact their prescriber. The decision to honor a member’s request for authorization of a replacement supply is based on the professional judgement of the prescriber. Prescribers may initiate a prior authorization request for a lost or stolen medication by contacting the eMedNY Call Center at 800-343-9000. Replacement, if granted, will be approved for up to a 30-day supply of medication.
Please refer to NYRx Pharmacy Policy Manual for information on lost or stolen medication.
FAQ 182 When provider receives “Plan limits quantity” reject, what does that mean?
Published: July 26, 2023
Generally, drugs are limited to the FDA approved dosing, and most maintenance drugs have a 90-day supply limit.
FAQ 183 As shortages of medications continue, what is NYRx doing to assist members and providers?
Published: July 26, 2023
NYRx updates prescription claim editing based on current drug shortage information. For example, to assist with patient needs, NYRx may remove PA criteria for a drug or drug class based on shortages and/or leverage additional NDCs that may be available in the marketplace.
FAQ 184 Can pharmacies provide a 30 day-fill with adjustment refills for a prescription that is for a 90-day fill?
Published: July 26, 2023
A pharmacist should consult the prescriber for any requested changes to a prescription. Please refer to Article 137 of NYS Education Law for more information.
FAQ 185 What is the process for new product or biologic review for PDL inclusion?
Published: July 26, 2023
One of the Drug Utilization Review Board (DURB) responsibilities is to review therapeutic classes subject to the preferred drug program (PDP). The DURB may also need to review the drug or drug class before clinical criteria may be applied. Drugs will be evaluated on a case-by-case basis to determine if they are appropriate to add to the pharmacy formulary. More information on the DUR review and PDL lists/requirements can be found in the Pharmacy Provider Manual.
Stakeholder Engagement
FAQ 025 Will the All Stakeholder meeting be sent out the same way as the first meeting? If so, will anyone registered for the July 13 meeting receive an invite for future meetings?
Updated: May 14, 2021
Yes. Information regarding future stakeholder meetings will be sent out via the MRT LISTSERV.
FAQ 026 Where can I get a copy of the All Stakeholder meeting presentations?
Updated: July 8, 2022
Presentation copies for All Stakeholder meetings are posted on the NYS DOH MRT II NY Medicaid Pharmacy Program (NYRx) website under the "Stakeholder Engagement" section and are organized by date.
FAQ 028 Has NYS DOH considered gathering input from individuals and families to support the transition of the Medicaid pharmacy benefit?
Updated: July 8, 2022
The All Stakeholder meetings have been established to update stakeholders and to gather input from all stakeholders, including individuals and families, and those that represent them.
FAQ 029 When will the Technical Workgroup meetings with the Managed Care Plans (MCPs) begin? Also, will the Technical Workgroup meetings be to the public?
Updated: July 8, 2022
The Technical Workgroup meetings began on July 21, 2020 and will be held bi-weekly thereafter. The meetings are not to the public.
FAQ 030 Will Pharmacy Directors for all Managed Care Plans (MCPs) be included in the Technical Workgroup meetings? What organizations are represented in those meetings? How will the agendas for the Technical Workgroups be created and how can MCPs provide input?
Updated: September 4, 2020
The Technical Workgroup is composed of Pharmacy Directors of each Managed Care Plan (MCP). NYS DOH will lead targeted discussions regarding specific topics and issues that require clarification and resolution in order to move the transition forward. MCPs will assist with the development of discussion documents and recommendations.
FAQ 049 Where can information be found regarding Technical Workgroup meeting discussions?
Updated: July 8, 2022
Outputs from Technical Workgroups will be posted on the NYS DOH MRT II NY Medicaid Pharmacy Program (NYRx) website once finalized.
FAQ 050 If I am not a member of the 340B Advisory Group or Technical Workgroup how can I participate in the Pharmacy Benefit Transition?
Updated: July 8, 2022
Stakeholders who are not members of the 340B Advisory Group or Technical Workgroup can participate in the Pharmacy Benefit Transition by attending the All Stakeholders meetings. The All Stakeholders meetings began on July 13, 2020 and occur the third Monday of each month. Stakeholders should subscribe to the MRT LISTSERV to receive announcements and registration links for the meetings (typically sent out 1 week in advance of the meeting). Additionally, the MRT LISTSERV is a valuable resource for staying up to date and informed about website updates and resource postings.
FAQ 084 I subscribed to the MRT LISTSERV but have not received any messages. How can I ensure I am signed-up to receive messages?
Published: November 5, 2020
If you are experiencing issues with receiving MRT LISTSERV messages or subscribing, please contact mrtupdates@health.ny.gov for assistance. The MRT Team will be able to verify your subscription or manually subscribe you.
FAQ 137 Who should providers contact for inquiries about the NYRx pharmacy program?
Updated: October 1, 2024
- Policy and coverage questions may be sent to NYRx@health.ny.gov.
- For provider enrollment and billing questions can be directed to the eMedNY Call Center at (800) 343-9000.
- For provider assistance with prior authorizations, clinical concerns, and the Preferred Drug Program, contact the Prime Therapeutics Clinical Call Center at (877) 309-9493.
Scope of Benefits
FAQ 031 What drugs and supplies are included in the transition?
Updated: December 14, 2022
The transition will include covered outpatient drugs and other products covered under the Medicaid Pharmacy Program. This includes outpatient prescription and over-the-counter drugs, diabetic, incontinence and other supplies. It does not include physician administered (J-Code) drugs. More information regarding what drugs and products are included in the NYRx Medicaid Pharmacy Program can be found within the Medicaid List of Reimbursable Drugs (Formulary File) and the List of OTC Categories and Supply Codes .
FAQ 051 Will the pharmacy transition Scope of Benefits document be updated as the transition progresses? What will happen beginning April 1, 2023, if managed care member is on a non-formulary/non-preferred medication that requires prior authorization in the NYRx program? Will there be a Prior Authorization (PA) process for certain medications that are subject to the pharmacy benefit transition?
Updated: October 12, 2022
The Scope of Benefits document will be updated and clarified based on stakeholder comments or questions. Information regarding specific outpatient drugs covered by the NYRx Medicaid Pharmacy program, and whether a prior authorization is required can be found on the eMedNY website.
When the pharmacy benefit transitions to NYRx, many Managed Care (MC) members will be able to continue taking their medication, without needing prior authorization. NYS DOH will leverage clinical editing criteria which may allow for members to continue to receive non-formulary/non-preferred medication. Additionally, prior authorizations established in Managed Care will continue to be honored and could allow for non-formulary/non-preferred drug coverage. Furthermore, there will be a transition period from April 1, 2023 through June 30, 2023. During this period, members will be provided with a one-time, temporary fill for drugs that would normally require prior authorization under the NYRx Preferred Drug Program (PDP). This allows additional time for prescribers to either seek prior authorization or change to a preferred drug, which does not require prior authorization. Refer to FAQ 113 for information on the Transition Period.
FAQ 052 Will regular prescriptions such as antibiotics and maintenance drugs still be covered under Managed Care (MC)?
Published: September 4, 2020
Outpatient Antibiotics and maintenance medications will be covered by the NYRx Medicaid Pharmacy program, when billed by a pharmacy. Information regarding specific outpatient drugs covered under the NYRx program can be found on the eMedNY website.
FAQ 053 Will Long-Acting 2nd generation injectables be covered as a pharmacy benefit when given in a clinic setting?
Published: September 4, 2020
Long Acting 2nd generation antipsychotics, when administered by a physician or other practitioner in a clinic setting and billed on an institutional or medical claim form will continue to be covered by the member's managed care plan.
FAQ 054 How are Opioid Use Disorder (OUD) and Alcohol Use Disorder (AUD) drugs impacted by the pharmacy benefit transition, specifically:
Updated: June 20, 2023
- For Opioid Use Disorder (OUD) and Alcohol Use Disorder (AUD) post pharmacy benefit transition, can providers continue to prescribe medications that have historically provided the best results for patients? For example, if prior to the pharmacy benefit transition a patient was treated with a brand-name medication, can providers continue to prescribe that without a Prior Authorization (PA)?
Outpatient drugs that are used for OUD and AUD are covered under the NYRx Medicaid Pharmacy Program and all are included in the Statewide Medication Assisted Treatment(MAT) Formulary. As the pharmacy benefit transitioned to NYRx on April 1, 2023, most managed care members have been able to continue taking their medication, without needing prior authorization.- Alternatively, how will drugs being used off-label be impacted?
The NYRx Pharmacy Program covers drugs that are indicated for FDA approved/compendia supported uses. Compendia support does include off-label uses that have proven efficacy. The official specific references currently identified can be found in the Social Security Act Section 1927(g)(1)(B)(i).- Is the statute still applicable that all Food and Drug Administration (FDA) approved medications for Opioid Use Disorder (OUD) and Alcohol Use Disorder (AUD) are approved without Prior Authorization (PA)?
See FAQ 054b above.
FAQ 057 How will the pharmacy benefit transition impact Durable Medical Equipment (DME) specifically fulfilled by home delivery suppliers or fulfilled at the pharmacy?
Updated: July 8, 2022
Only pharmacy supply and procedure codes are subject to the pharmacy benefit transition unless otherwise stated within the Pharmacy Scope of Benefits. Pharmacy billing guidance and a list of supply codes for pharmacies and DME suppliers can be found on the eMedNY Pharmacy website. DME billing guidance is available as a PDF.
FAQ 058 How will the pharmacy benefit transition impact mastectomy supplies such as wigs, etc.?
Updated: July 8, 2022
Mastectomy care is subject to the pharmacy benefit transition and will therefore be covered under the Medicaid Fee-For-Service (FFS) program. Breast and hair prosthesis will be the responsibility of the Managed Care Plans (MCPs). For more information, please review the Pharmacy Supply and Procedure Manual and the Pharmacy Scope of Benefits.
FAQ 059 Can NYS DOH please explain how diabetic supplies will be impacted after the transition of the Medicaid pharmacy benefit to Medicaid NYRx Pharmacy Program is complete specifically related to the following:
- Will NYS DOH be using NDC or HCPCS codes for Insulin Pumps (including external ambulatory infusion pumps), Insulin Pump Supplies and Integrated Continuous Glucose Monitoring (CGM)?
- How will insulin pumps, pump supplies and integrated CGM be authorized? Will NYS DOH review each submitted request?
Updated: July 8, 2022
- Diabetic supplies found on the NYS Medicaid Preferred Diabetic Supply Program (PDSP) List should be billed via an NDC. If the product is not on the PDSP list, then it should be billed via a HCPCS code. Further clarity is provided below:
- Disposable insulin pumps should be billed via an NDC as a pharmacy claim to FFS.
- Insulin pump supplies should be billed via a HCPCS code as either a pharmacy claim or medical claim to FFS.
- Preferred CGMs should be billed via an NDC as a pharmacy claim to FFS.
- Non-preferred CGMs should be billed via a HCPCS code as a medical claim to FFS.
- Non-disposable insulin pumps and integrated CGM/insulin pumps (i.e. external ambulatory infusion pumps, insulin) remain the responsibility of the Managed Care Plans (MCPs) as defined within the Pharmacy Scope of Benefits.
- CGMs and disposable insulin pumps will be authorized if they meet program criteria. Products that do not meet program criteria will be manually reviewed. For more information please refer to the following resources:
FAQ 072 Vivitrol (extended-release naltrexone for injectable suspension), a provider administered medication, is listed on the PDL and is currently covered under the pharmacy benefit. This product is affected by the SUPPORT Act, legislation mandating that Medicaid will be required to cover all products considered Medication Assisted Therapy (Vivitrol is indicated for the prevention of relapse to opioid disorder). Will Vivitrol be included in the transition even though it is a physician-administered drug or will managed care plans continue to cover it?
Updated: July 8, 2022
Vivitrol is subject to the transition and will be covered under the Medicaid NYRx pharmacy benefit. Managed Care Plans (MCPs) will continue to be responsible to cover Vivitrol for their members when it is billed as a medical or institutional claim.
FAQ 075 How are DME code E0784 insulin pumps impacted by the pharmacy benefit transition?
Updated: July 8, 2022
External ambulatory infusion pumps for insulin are not part of the pharmacy benefit transition and will remain the responsibility of the Managed Care Plans (MCPs). More information can be found within Appendix A of the Pharmacy Scope of Benefits.
FAQ 076 Regarding the following Durable Medical Equipment (DME) categories such as: diabetes, ostomy, incontinence, etc.:
- How will the pharmacy benefit transition impact the above-mentioned categories? Will products within these categories be covered under Fee-For-Service?
- After the transition how should DME products in the above-mentioned categories be billed? Ex: via pharmacy, DME, or both?
Updated: June 20, 2023
- These products fall within the Pharmacy Procedures and Supply Codes Manual and are subject to the pharmacy benefit transition and will be covered under Medicaid Fee-For-Service (FFS).
- Effective April 1, 2023, these supplies may be billed via the pharmacy NCPDP format or via the medical claim format. Information regarding pharmacy billing guidance and a list of supply codes for pharmacies and DME suppliers can be found on the eMedNY Pharmacy website. Information regarding DME billing guidance is available as a PDF.
FAQ 077 What Durable Medical Equipment (DME) products are not covered after the pharmacy benefit transition effective April 1, 2023?
Updated: July 8, 2022
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies not found within in the Pharmacy Procedures and Supplies Manual are not subject to the transition and will remain the responsibility of the Managed Care Plans (MCPs). For more information, refer to Appendix A of the Pharmacy Scope of Benefits.
FAQ 078 Will continuous glucose monitoring (CGM) devices be able to be filled under a member's medical benefit or only pharmacy benefit?
Updated: July 8, 2022
Preferred CGM devices should be billed via the Medicaid NYRx Pharmacy Benefit and are subject to the Preferred Diabetic Supply Program (PDSP) list. Information regarding pharmacy billing guidance and a list of supply codes for pharmacies and DME suppliers can be found on the eMedNY Pharmacy website.
Non-Preferred CGM devices should be billed under the medical benefit. Information regarding DME billing guidance is available as a PDF.
FAQ 085 The Medicaid NYRx formulary list does not contain the same oncology medications covered by Managed Care Plans (MCPs) today. How will NYS DOH mitigate potential issues that arise from these gaps in covered medications?
Updated: July 8, 2022
NYS DOH is evaluating MCP pharmacy claim encounters to determine potential differences in coverage for medications. The New York State Medicaid Pharmacy program, NYRx, covers medically necessary FDA approved prescription and select non-prescription drugs for Medicaid NYRx members based on program rules. NYS DOH is evaluating MCP pharmacy claim encounters to determine potential differences in coverage areas for medications.
Oncology medications that are typically administered by practitioners may not be on the Medicaid NYRx formulary as they are not considered part of the pharmacy benefit. However, they are still a covered Medicaid benefit. MCPs will continue to make practitioner administered oncology medications available when they are billed as a medical or institutional claim.
FAQ 091 Will Durable Medical Equipment (DME) supplies found within the Pharmacy Procedure and Supply Codes manual that are billed as a medical claim be subject to the Pharmacy Benefit Transition?
Updated: June 20, 2023
Yes, the Pharmacy Procedures & Supply Codes manual contains products that were subject to the transition, which will be able to be billed as either a pharmacy claim via NCPDP or billed as a medical claim through Fee-For-Service (FFS). Effective April 1, 2023, these supplies are no longer to be billed to the Managed Care Plan (MCP).
FAQ 098 Will all prior authorization (PAs) approvals issued prior to April 1, 2023 be honored after the transition (effective April 1, 2023)?
Updated: June 20, 2023
Prior Authorizations that were issued by Medicaid Managed Care (MMC) plans prior to April 1, 2023 (that are active/valid after April 1, 2023) have been honored by the Medicaid Pharmacy program, NYRx. This includes clinical PAs that also require authorization under the Medicaid NYRx Pharmacy program.
FAQ 117 Will there be new therapeutic classes added to the Preferred Drug Program (PDP) that are not being reviewed currently?
Published: November 8, 2022
The existing process which requires the Drug Utilization Review Board (DURB) to review new drugs and drug classes for inclusion in the PDP will continue, and new therapeutic classes may be added in the future.
FAQ 118 Does the pharmacy benefit transition affect the Elderly Pharmaceutical Insurance Coverage (EPIC) program?
Published: November 8, 2022
No. The Elderly Pharmaceutical Insurance Coverage (EPIC) program is separate from the NYS Medicaid Program. and will not be affected by the transition.
FAQ 128 Do all non-preferred medications require Prior Authorization?
Published: December 14, 2022
If the program criteria is met then the non-preferred drugs may not require prior authorization.
FAQ 129 If a drug is not on the NYRx formulary, will members still be able to receive the medication with Prior Authorization?
Published: December 14, 2022
Under NYRx, members have access to a very comprehensive list of drugs/drug classes. All members will be subject to the same coverage and utilization management protocols. If there is a drug or drug class that is not on the formulary, a medical necessity request can be submitted for review.
FAQ 138 Will there be any changes to how specialty drugs are handled? For example, will pharmacies need to have specialty pharmacy accreditation, or any other additional policies for specialty drugs?
Published: January 12, 2023
NYRx does not require additional enrollment requirements or accreditations to dispense specialty drugs. Pharmacies enrolled in Medicaid Fee-For-Service (FFS) may dispense and bill for covered outpatient drugs.
FAQ 139 Does the NYRx pharmacy program publish the clinical criteria for drug prior authorizations for members and providers to review?
Updated: October 1, 2024
NYRx, the Medicaid Pharmacy program publishes a full listing of drugs and clinical criteria for the Preferred Drug Program, Clinical Drug Review Program (CDRP), DUR Program, Brand Less than Generic Program (BLTG), Dose Optimization Program and the Mandatory Generic Drug Program (MGDP)on the Prime Therapeutics Medicaid Administration Website.
FAQ 146 What compounds will require Prior Authorization, and will Prior Authorization be required for patients already receiving compounds without previous Prior Authorization?
Published: February 17, 2023
The NYRx compound policy is outlined in the December 2020 Medicaid Update article Compound Policy: A Reminder and Clarification. Criteria for topical compounds can be found in the NYRx Preferred Drug List (page 77).
Additional information about topical compounds can be found in the November 2018 Medicaid Update article Update on Medicaid Fee-for-Service Prior Authorization of Topical Compounded Drug Products.
FAQ 147 Currently Home Infusion pharmacies bill Medicaid Fee-For-Service for enteral formula to the pharmacy benefit (ex. codes: B4150, B4152, etc.), and supplies are billed medically (ex. codes: B4034, B4088, etc.). Following the transition, will pharmacies bill for both enteral formula and supplies to the pharmacy benefit?
Updated: June 20, 2023
The existing Fee-For-Service billing processes for these services is continuing to be utilized following the transition to NYRx on April 1, 2023. See pages 5 through 8 of the Medicaid Pharmacy Procedure Codes for a list of services and supplies that have or have not been affected by the transition.
FAQ 148 Spravato is currently approved as a pharmacy benefit, however some Managed Care Plans (MCPs) cover the drug as a bundled benefit, medication and observation (Code G2083). Following the transition, will Spravato continue to be paid as a pharmacy benefit or a bundled benefit?
Published: February 17, 2023
The HCPCS codes "G2082" and "G2083" should not be billed to the NYS Medicaid program. These codes are a bundled payment and are not eligible for rebate collection per federal rule and, therefore, are not listed as covered by the program. These codes are only authorized for use on Medicare crossover claims. Spravato may be billed as pharmacy or medical benefit per the guidance below.
See the March 2022 Medicaid Update Article titled Pharmacy and Medical Billing Guidance for SPRAVATO® (esketamine) and the August 2022 MU Article titled Practitioner Administered Drug Update: New York State Medicaid Fee-for-Service Policy Guidance for SPRAVATO® (Esketamine) Nasal Spray for additional information.
FAQ 149 How will the transition affect home health patients? Will Physician Administer Drugs administered in a home health setting be billed as a pharmacy benefit?
Published: February 17, 2023
Physician administered drugs not included on the List of Reimbursable drugs will be reimbursed using the medical benefit irrespective of location of administration. Please see the Provider Manual for NYRx members and refer to the Managed Care Plan for their processes for Managed Care enrollees. More information can also be found in FAQ 031 and FAQ 048.
The Department continues to evaluate the potential additions of more physician administered drugs on the pharmacy outpatient formulary. For the most updated information, please refer to the NYRx Formulary File.
FAQ 157 Following the Transition, can pharmacies bill NYRx for enteral formula (ex: codes B4150, B4152, B4161) and those supplies (ex: codes: B4034, B4088)? How will enteral or parenteral infusion pumps (ex. Codes: B9002, B9004) be billed?
Published: March 17, 2023
Enteral and parenteral nutrition, family planning and medical/surgical supplies found in the Pharmacy Procedures and Supply Codes are subject to the transition and can be billed to NYRx as a pharmacy or medical claim.
Infusion pumps for enteral or parenteral nutrition found in the Sections 4.4, 4.5, 4.6, and 4.7 of the Durable Medical Equipment, Prosthetics and Supplies Manual are not subject to the transition and remain the responsibility of the MC plans.
FAQ 186 Is Wegovy or Ozempic (semaglutide) covered under NYRx for weight loss, or are these drugs still the responsibility of Managed Care Plans (MCPs)?
Published: July 26, 2023
NYRx does not cover certain diagnoses and certain drugs or drug classes due to federal regulations. At this time, NYRx does not cover medications, such as Wegovy or Ozempic, when indicated for the treatment of weight loss.
For more information regarding excluded drugs under the Medicaid benefit, please see the April 2022 Medicaid Update.
FAQ 187 How can providers view what biologics are covered by NYRx?
Published: July 26, 2023
Please refer to the NYRx preferred drug list (PDL) for details about coverage criteria for drugs covered by NYRx with utilization management. Additionally, Providers can view the Medicaid Pharmacy List of Reimbursable Drugs for a complete listing of drugs, including biologics covered by the NYRx pharmacy benefit. Physician administered drugs, including biologics, continue to be covered by the Managed Care Plans (MCPs).
FAQ 188 Can pediatric members receive waived fees for compound medications?
Published: July 26, 2023
Children, under 21 years of age, enrolled in Medicaid are exempt from copayments. Pharmacies must accept reimbursement as payment in full. It is inappropriate for a NYS Medicaid provider to request or charge additional fees to a member.
FAQ 189 Can providers submit medication claims through the medical benefit or is the intent that all claims go through the pharmacy benefit?
Published: July 26, 2023
Medical providers can continue to submit medication claims using the medical benefit. Please see the Provider Manual for NYRx members and refer to the Managed Care Plan for their processes for Managed Care enrollees. Medications found on the List of Reimbursable Drugs are also covered as a pharmacy benefit.
FAQ 190 Will breast pumps be covered under NYRx, and will this change prescribing of these items
Published: July 26, 2023
Breast pumps, other than hospital grade pumps, are included in the transition, please refer to the Scope of Benefits document. There is no change to prescribing providers.
Please refer to the DME manual for information on pages 9-12. For more information regarding DME supplies reach out to ohipmedpa@health.ny.gov.
FAQ 191 What is the process to receive a prior authorization for ostomy supplies when a member needs a larger supply then prescribed by their provider?
Published: July 26, 2023A prior approval request must be submitted for any amount over the allowed quantities. This approval should include documentation supporting the medical necessity of the request amounts. This request can be submitted via paper PA or ePACES with uploaded documentation. For specific procedural guidance, please refer to the March 2023 Medicaid Update, the DME policy guidelines on the eMEdNY site or contact DME by email at ohipmedpa@health.ny.gov for information on billing of DME supplies.
Member Impact
FAQ 032 Will members receive a new pharmacy insurance card to carry, or if they do not have their Medicaid card can members continue to use their Managed Care Health Plan (MCP) card at the pharmacy? Will member ID numbers change?
Updated: November 8, 2022
Existing Medicaid members will not receive a new NYS Benefit Card, also known as the Common Benefit Identification Card (CBIC), and there will be no change to member ID numbers. Members can show either their existing NYS Benefit Card or their Managed Care Health Plan Card at the pharmacy.
FAQ 086 Will there be a designated specialty pharmacy to deliver physician administered drugs to the provider's office or can the Medicaid Managed Care (MC) member go to a pharmacy, including retail, enrolled in the Medicaid Fee-For-Service (FFS) Program to receive them?
Published: November 5, 2020
There will not be designated specialty pharmacies within the Medicaid NYRx Pharmacy Program nor are there any presently. Members will be able to access any NYRx pharmacy for drugs that are on the outpatient NYRx formulary. NYS DOH is reviewing the physician administered drugs and may add some of those drugs to the outpatient NYRx formulary.
Lastly, NYS DOH is working closely with the Managed Care Plans to ensure that they (MCPs) will be able to provide members continued access to those drugs.
FAQ 087 After the Pharmacy Benefit Transition, who should a member contact with questions or complaints associated with the Durable Medical Equipment (DME) supplies (i.e., brand, quality, timeliness, etc.) or denials?
Updated: July 8, 2022
After April 1, 2023, members and providers with questions or complaints associated with DME/supplies subject to the transition, should contact 800-342-3005 or ohipmedpa@health.ny.gov.
FAQ 099 After the transition, what will the patient-pharmacy experience be like for members transitioning their outpatient pharmacy benefit from Managed Care (MC) to the Medicaid Pharmacy Program, NYRx
Updated: July 8, 2022
Starting on April 1, 2023, Medicaid Managed Care (MMC) members should present either their MMC plan or Medicaid Identification Card to their pharmacist and remind him/her about the transition to Medicaid NYRx. Both cards contain the Client Identification Number (CIN), which the pharmacist uses to submit their claims to the Medicaid NYRx program.
For most members, there will be no change at the pharmacy counter.
Members should review the letter notifying them of the change, to be sure that their pharmacy takes the Medicaid Pharmacy Program, NYRx (most pharmacies do), and that their drugs are covered. Refer to FAQ 051 and FAQ 098 for information regarding the transition period and prior authorizations previously granted by MMC plans. The PowerPoint presentation (slides 4-6), from the December 22, 2020 All Stakeholder Meeting also provides information regarding what members can expect.
FAQ 100 How can patients verify if their current pharmacy is enrolled in the Medicaid Pharmacy Program, NYRx, or locate a pharmacy that is enrolled in NYRx?
Updated: July 8, 2022
Patients can verify if their current pharmacy is enrolled by accessing the eMedNY website for members. The resource is accessible here. Select the tool for "Find a Pharmacy/Medical Equipment Supplier."
FAQ 107 How will members be affected when receiving services from an out-of-state non-enrolled provider following the transition?
Updated: June 20, 2023
NYS DOH has existing processes in place to allow for the approval of emergency medication supply when a member receives services from an out-of-state non-enrolled provider, which is continuing to be leveraged now that the Transition has occurred.
FAQ 119 Will the pharmacy benefit transition change the way patients receive their oral medication directly from their physician? Will patients need to go to an enrolled mail-order pharmacy to receive their prescriptions, rather than directly from their physician?
Published: November 8, 2022
No. Patients still have the option to receive their oral prescriptions directly from their physician. Medical billing will not be impacted by the pharmacy benefit transition. The transition will not change the Managed Care Plan responsibility for developing coverage and billing policies for prescription drugs that are billed on medical and institutional claims.
NYSDOH Fee-For-Service has expanded medical billing [New York State Medicaid Update. (2022, July). Policy Clarification for Practitioner Dispensing] so that practitioners can use the existing medical claims format to be reimbursed for drugs furnished to Medicaid Fee-For-Service patients. This expands access so that all practitioners serving Medicaid Managed Care and Fee-For-Service patients can use the same claims format. The use of existing medical billing does not change how Medicaid patients can obtain their prescriptions, and use of this existing billing procedure does not add extra steps or complex barriers preventing patients from receiving treatment. Allowing all Medicaid physicians to bill for medications furnished to their patients, using the established billing procedure ensures patient care coordination and drug availability at the point of service.
FAQ 130 Are most major pharmacy chains, and independent pharmacies located in the state enrolled in NYRx? Is there any data about the percentage of pharmacies in New York State already enrolled in NYRx?
Published: December 14, 2022
Most major chains and independent pharmacies located in New York are enrolled in the Medicaid program. Data regarding the number of pharmacies enrolled in the Medicaid program may be found on the Medicaid Enrolled Provider Listing.
FAQ 131 Effective April 1, 2023, are members allowed to pick which pharmacies and DME supplier to utilize or must they stay with the providers to which their Managed Care Plan (MCPs) assigned them?
Published: December 14, 2022
Yes, members can use one of the 5,700+nparticipating pharmacy or DME supplier enrolled in NYRx.
FAQ 132 What if a pharmacy does not take NYRx?
Published: December 14, 2022
A member will need to use an NYRx enrolled provider. If a member's current pharmacy does not take NYRx, a member should ask their pharmacist to transfer a refill to a participating pharmacy or ask their doctor to send their prescriptions to a participating pharmacy.
FAQ 150 Will members be able to receive their medication in the cases of traveling out-of-state or lost medication?
Published : February 17, 2023NYS Medicaid ensures an ample supply of medication(s) to accommodate for most temporary absences and allows a 90-day supply for most maintenance medications.
For more information, refer to the August 2021 Medicaid Update article titled, Clarification and Reminder: Pharmacy Providers Servicing Medicaid Fee-for-Service Members.
FAQ 151 When will member notices be sent?
Updated: March 17, 2023Members notices of change were sent to members in February. Please refer to Member Notice of Change Mailing Tracker for a schedule of the mailings. Additionally, please visit the NYRx Information for Medicaid Members website for member information.
Members also can contact their Managed Care Plan (MCP) for the letter translated in their preferred language.
FAQ 158 Following the Transition, are deliveries allowed? What documentation is needed for deliveries?
Updated: June 20, 2023
Delivery of prescription drugs, over-the-counter products, medical/surgical supplies, and medical equipment (DME) is an optional service that can be provided to Medicaid member's home or current residence including facilities and shelters. Pharmacies/DME providers must obtain a signature from the Medicaid member, their caregiver or their designee to confirm receipt of the prescription drugs, over-the-counter products, medical/surgical supplies, or DME items. Claim submission is not proof that the prescription or fiscal order was actually furnished.
For more information on delivery, please refer to page 12 of the Pharmacy Provider Manual.
FAQ 159 Can members use the Pharmacy Search Tool, on eMedNY, to search for specialty pharmacies that provide limited distribution medications? Will the Department publish a list of those pharmacies for members?
Published: March 17, 2023
Members must utilize a NYS Medicaid FFS enrolled pharmacy. Drugs covered by NYRx subject to limit distribution will be available from Medicaid enrolled limited distribution pharmacies. If these limited distribution pharmacies are not located in NYS they will not show up in the look up tool. The pharmacy should be contacted to confirm they are enrolled in NYRx for this benefit. Providers can also check enrollment through the Medicaid Enrolled Provider List.
FAQ 160 What is being done to help transition care for patients currently using specialty pharmacies that may not be in-network with NYS Medicaid FFS but whose medications are on limited distribution lists?
Updated: June 20, 2023
Limited Distribution drugs remain available following the Pharmacy Benefit Transition on April 1, 2023. NYRx has pharmacies enrolled that dispense limited distribution drugs, most of which are currently servicing Managed Care enrollees. Managed Care Plans are responsible for transitioning members to enrolled pharmacies if the pharmacy they are utilizing is not enrolled in NYRx. Members were noticed if they needed to choose another pharmacy and may reach out to their Managed Care Plans for questions for their specific needs.
FAQ 161 Are prescriptions required for all covered OTCs? Can a member request these items from pharmacy without an prescription?
Published: March 17, 2023
A prescription or fiscal order is required for non-prescription OTCs. There are some exceptions, and a fiscal order or prescription is not required for OTC emergency contraception for Medicaid-eligible females, and Covid-19 test kits.
FAQ 162 What is the expected member experience when they go to the pharmacy post-Transition?
Prescribers and pharmacies have received extensive information regarding the Pharmacy Benefit transition to ensure a positive experience for NY Medicaid members.
FAQ 163 Following the Transition, how will fair hearings regarding pharmacy issues be handled?
Updated: June 20, 2023
Fair hearings are a process administered by the Office of Temporary and Disability Assistance (OTDA), which is operational today and has continued to be utilized following the Transition. However, by leveraging NYRx's Prior Authorization request process, most of these issues can be addressed without utilizing the fair hearing process.
FAQ 164 Following the Transition, how will a member who currently receive prescriptions through the mail be affected?
Published: March 17, 2023
Members may continue to receive their prescriptions from their mail order pharmacy as long as the pharmacy is enrolled in the NYRx program. To verify enrollment please visit the Search for a Pharmacy or Medical Equipment Supplier tool.
FAQ 169 Will copays still be able to be waived for patients expressing hardships?
Updated: June 20, 2023
There are no changes in the copay requirements, including the provider's responsibility to provide services when the member is unable to pay a copay. For information, please see the Pharmacy Manual (pages 45-46).
FAQ 170 Members are receiving rejections for Missing or Invalid (M/I) other coverage code, meaning secondary insurance should be billed because there is another payer as primary insurance on file. How should members be directed in this situation for resolution?
Published: May 12, 2023
If primary insurance coverage is no longer active or has changed, a member would need to contact either their Local District, NY State of Health or HRA NYC, depending on where they had their Medicaid eligibility determined, to update their Medicaid application. Please contact the Human Resource Administration (HRA) for New York City at (718) 557-1399 or the Medicaid Helpline (800) 541-2831. For Local District contact information please visit: New York State Local Departments of Social Services (LDSS) (ny.gov)
FAQ 175 How can members obtain limited distribution medications that are only available from an out-of-state pharmacy?
Published: June 20, 2023
NYRx enrolls pharmacies that dispense limited distribution drugs to ensure members have access Prescribers can work those pharmacies to provide the limited distribution drug to the member. For lists of Medicaid enrolled providers please visit:
FAQ 192 Did all Managed Care Plans (MCPs) provide members with new health plan ID cards reflecting the pharmacy benefit changes effective April 1, 2023?
Published: July 26, 2023
Managed Care Plans were not required to issue a new health plan ID card specific to the pharmacy benefit transition. Members may present their existing health plan ID card or the NYS Benefit Card, also known as the Common Benefit Identification Card (CBIC) card at the pharmacy.
FAQ 193 Will NYRx cover prescriptions transferring from one pharmacy to another or do members need to get a new prescription from the provider?
Published: July 26, 2023
Yes, NYRx does allow prescription transfers. New York State Education Law Article 137 Section 6810 (10-a) Title 8, New York Codes, Rules and Regulations Section 63.6 (a)(8), provisions are to be followed for prescription transfers. For Medicaid specific information regarding transfers please see the NYRx policy manual .
Foster Care
FAQ 033 To what extent are children and foster care programs affected by the pharmacy benefit transition? Will the foster care children transitioned to Managed Care in July 2021 transition back to Medicaid FFS for the transition?
Updated: June 20, 2023
As the pharmacy benefit has transitioned into the NYRx Medicaid Pharmacy program on April 1, 2023, children in foster care that are already enrolled in Managed Care Plans (MCPs) have begun to receive their outpatient pharmacy benefit through the NYRx program.
Foster care children that transition from FFS into a Managed Care Plan (MCP) for their medical benefit will continue to receive their pharmacy benefit through the NYRx program.
FAQ 108 Foster Care parents do not always receive the NYS Benefit card, also known as the Common Benefit Identification Card (CBIC), from the local Department Social Services (DSS), will the local Department of Social Services (DSS) provide Foster Care parents or Voluntary Foster Care Agencies (VCFA) with the member's CBIC card?
Published: October 12, 2022
Foster Care parents should contact the Voluntary Foster Care Agencies (VCFA) for assistance with obtaining necessary billing information. Foster Care parents can also show the Managed Care Health Plan Card which contains the Client Identification Number (CIN) the pharmacist uses to submit their claims to the Medicaid NYRx
Provider Impact
FAQ 034 How does the transition of the pharmacy benefit from Managed Care (MC) to Medicaid NYRx Pharmacy program affect providers?
Published: August 4, 2020
Providers that are prescribing outpatient drugs (or other products covered under the outpatient pharmacy benefit),for Managed Care (MC) members, will access the NYRx formulary and the Preferred Drug List to determine coverage parameters. Pharmacies that are billing for outpatient drugs for MC members will submit claims to the eMedNY system.
FAQ 092 Generic medications come in various prices. Sometimes pharmacies pay less than what the insurance is paying us (profit) and sometimes pharmacies pay more (loss). After the transition, how will the price for a generic drug be determined?
Updated: July 8, 2022
Covered generic medications will be paid in accordance with the Medicaid Pharmacy NYRx Pharmacy Reimbursement methodology.
FAQ 093 What is the exact amount that pharmacies will get paid to fill a Medicaid prescription after the transition? Currently, certain medications where this applies in the case of direct Medicaid patients have varied but have been capped at approximately $10?
Updated: July 8, 2022
Information regarding pharmacy reimbursement can be found within the Medicaid Pharmacy NYRx Pharmacy Reimbursement methodology.
FAQ 094 Will the pharmacy benefit transition provide an opportunity for mail-order pharmacy suppliers to obtain NYS Medicaid Pharmacy enrollment? In the past these enrollments have been denied to mail-order suppliers.
Updated: July 8, 2022
Pharmacies (mail order and non-mail order) that are currently serving Medicaid Managed Care members, but are not enrolled in the Medicaid FFS program, may submit their applications to the FFS program. The Department of Health will consider the number of Medicaid managed care members and claims currently being handled by pharmacy applicants.
Information for submitting applications can be found on page 10 within the October 2020 Medicaid Update Article entitled Attention: Pharmacies, Durable Medical Equipment, Prosthetics, Orthotics and Supply Providers, and Prescribers That are Not Enrolled in Medicaid Fee-for-Service.
FAQ 101 How will the transition impact medical suppliers who drop-ship supplies directly to patients and bill Managed Care (MC) today? After the transition, what will be the impact to these companies in terms of billing? Will these companies still be able to drop-ship and bill Fee-For-Service?
Updated: July 8, 2022
Delivery directly to a member's home is allowed under the Guidelines for the Delivery of Medical/Surgical Supplies and Durable Medical Equipment (pg.19) within the Durable Medical Equipment Manual Policy Guidelines. The guidelines specify the types of supplies that may be delivered, documentation required to be retained by the billing provider, and requirements and responsibility of the billing provider for lost or misdirected shipments.
Revised Guidelines will be available with the next Manual Update.
FAQ 102 How will Durable Medical Equipment (DME) supply companies who serve Medicaid Members but bill Managed Long Term Care (MLTC) be impacted by the transition? Will all MLTC patients need to transition? Will MLTC no longer be paying for supplies?
Updated: July 8, 2022
MLTC Plans are not impacted by the Pharmacy Benefit Transition. See FAQ 017.
FAQ 120 Will DME providers who are not pharmacies be able to bill certain medical supplies to NYRx for items that are considered "Pharmacy benefit only"?
Published: November 8, 2022
Yes, for more information please refer to the Scope of Benefits, Chart #2.
FAQ 103 How will the transition impact the daily operations of Pharmacies? For example, if a member has Medicaid Managed Care (MMC) such as Fidelis or HealthFirst, how will our pharmacy submit claims for these members beginning April 1, 2023?
Updated: July 8, 2022
Starting April 1, 2023, pharmacies will submit claims to the Medicaid Fee-For-Service (FFS) program, using the Client Identification Number (CIN), which can be found on the member's Medicaid or the MMC plan Identification Card. Additional information regarding claim submission can be found within the December 2020 Special Edition Medicaid Update.
FAQ 109 How will the transition impact Prior Authorization volume for providers?
Published: October 12, 2022
NYS DOH has taken the necessary steps to prevent an increase in Prior Authorization volume. These include:
- Utilizing a fully automated system, operated by Kepro, where claims that meet clinical criteria will adjudicate and automatic approvals are generated 50% of the time. By leveraging this process members may be allowed to continue receiving non-formulary/non-preferred medications if previously established on those medications
- Implementing a member transition period that allows members to receive a one-time fill of a non-formulary/non-preferred product. This allows additional time for prescribers to either seek prior authorization or change to a preferred drug, which does not require prior authorization.
- Honoring prior authorizations issued by Medicaid Managed Care (MMC) prior to April 1, 2023 will allow for previously approved drugs to continue to be approved. This includes clinical PAs that also require authorization under the Medicaid NYRx Pharmacy program.
FAQ 110 Does a physician have to be enrolled in Medicaid Fee-For-Service (FFS) program (NYRx) to prescribe for a Medicaid member?
Updated: November 8, 2022
Pharmacies and practitioners must be enrolled in NYS Medicaid Fee-For-Service (FFS), to service Medicaid members. For exceptions, refer to FAQ 112. Information on how to enroll in NYS Medicaid (FFS) can be found here.
FAQ 121 If a pharmacy is currently enrolled in the NYS Medicaid Fee-For-Service (FFS) program, does that pharmacy need to enroll in the NYRx pharmacy program?
Published: November 8, 2022
Additional enrollment is not required for pharmacies that are currently enrolled in NYS Medicaid FFS. NYRx is the new name for the pharmacy benefit under the New York State Medicaid Program. Nothing has changed with the Medicaid pharmacy program except the name. Pharmacies must maintain enrollment with NYS Medicaid FFS to continue to service Medicaid members.
FAQ 122 Do OPRA (Ordering, Prescribing, Referring or Attending) providers need to be enrolled in NYS Medicaid Fee-For-Service program (NYRx)?
Published: November 8, 2022
No additional enrollment action is needed from practitioners who are enrolled with NYS Medicaid as an ordering, prescribing, referring, and attending (OPRA) provider.
Practitioners enrolled with Medicaid as an OPRA provider are considered to be enrolled in NYS Medicaid Fee-For-Service (FFS) as a qualified non-billing provider. More information on how to check a provider's enrollment status can be found with in the June 2022 Medicaid Update Article: Reminder: Medicaid Enrollment Requirements and Compliance Deadlines for Managed Care Providers.
Providers who wish to enroll as non-billing OPRA provider may do so on the eMedNY "Provider Enrollment and Maintenance" web page.
FAQ 111 Do providers need to enroll in Medicaid Fee-For-Service (FFS) individually or with their clinical site?
Published: October 12, 2022
Individual providers should be enrolling in Medicaid Fee-For-Service (FFS). Practice sites may facilitate enrollment for providers; however, providers must sign the NYS Medicaid FFS contract agreement individually. For more information, please visit the eMedNY Practitioner Group Enrollment page.
FAQ 112 Does the NYS Medicaid Fee-For-Service (FFS) Program (NYRx) allow an override for non-enrolled providers?
Published: October 12, 2022
There are existing processes in place to process claims from non-enrolled providers. Circumstances in which the override process may be used, include medical emergencies or for services provided by an intern, resident, or foreign physician who cannot enroll in the NYS Medicaid Program. Please see the April 2022 Medicaid Update for more information.
FAQ 123 If a standing order to administer vaccinations in the pharmacy is issued by an out-of-state practitioner that is not enrolled in Medicaid Fee-For-Service (FFS), will the vaccination be reimbursed? If not, could the pharmacy utilize an override?
Published: November 8, 2022
No. To be eligible for reimbursement by the Medicaid program, the practitioner that issues the standing order must be enrolled in Medicaid Fee-For-Service (NYRx) and the non-enrolled prescriber override should not be utilized in this scenario.
FAQ 113 What will be the duration of the transition period/fill and what is the criteria for the transition logic to apply at Point of Service (POS)? Will NYS DOH outreach prescribers before the transition period ends to prevent Point of Service (POS) rejects?
Published: October 12, 2022
Prior to the transition period, NYS DOH will be outreaching high volume prescribers of non-formulary/non-preferred products to educate them on the NYRx preferred drug program and clinical criteria. Additionally, during the transition period, from April 1, 2023, to June 30, 2023 (90 days), NYS DOH will be conducting outreach to prescribers to inform them of the members receiving non-preferred products in order to familiarize with Preferred Drug Program. For more information on the transition fill, refer to FAQ 051.
FAQ 124 What is the supply quantity for the one-time fill during the transition period?
Published: November 8, 2022
During the transition period from April 1, 2023 through June 30, 2023, members will be provided with a one-time, temporary fill for up to a 30 day supply of a drug that would normally require prior authorization under the NYRx Preferred Drug Program (PDP). This allows additional time for prescribers to either seek prior authorization or change to a preferred drug, which does not require prior authorization. Refer to FAQ 051 and FAQ 113.
FAQ 125 Following the pharmacy benefit transition, will practitioner billing remain the same for dispensing prescription drugs to Medicaid patients?
Updated: June 20, 2023
Practitioners who dispense prescription drugs to Medicaid patients submit claims through medical billing. Medical billing is not impacted by the pharmacy benefit transition. The transition did not change the Managed Care Plan responsibility for developing coverage and billing policies for prescription drugs that are billed on medical and institutional claims.
FAQ 126 Will NYRx have access to a patient's previous prescription history while they were under Medicaid Managed Care?
Published: November 8, 2022
Yes, NYRx has access to historical prescription claims and clinical editing has the capability to look back at all claims submitted from the Medicaid Managed Care Plans.
FAQ 133 When contacting the Prime Therapeutics Clinical call center to obtain a prior authorization, how are those calls handled?
Updated: October 1, 2024
When a provider contacts the call center, they will speak with a pharmacy technician. The technician will collect relevant information and ask the appropriate criteria questions. If the technician can approve the prior authorization based on the provider's responses, a prior authorization will be created. If the call needs to be escalated because the technician cannot approve, it may go to the pharmacist for a more in-depth clinical conversation. If further discussion is warranted, a peer-to-peer consultation may be utilized if necessary.
FAQ 134 How do providers perform an eligibility check for members?
Published: December 14, 2022
Pharmacies can check a member's Medicaid eligibility status through any of the following methods:
Method Summary E1 Transaction Instructions for E1 transactions begin on page 10 of the NCPDP D.0 Standard Companion Guide ePACES Providers must have an ePACES account and the member's CIN to check their eligibility status.
If the CIN is not available, providers must have the member's:
- First Name and Last Name
- Date of Birth
- Social Security Number (SSN)
- Gender
Telephone Verification System (MEVS) 1-800-997-1111 Providers must have the following information:
- Member's CIN
- Provider's National Provider Identifier (NPI) or Medicaid Management Information System (MMIS) Number
- Ordering Provider's NPI (if applicable)
FAQ 140 Under the NYRx program, are there are any changes to the rules regarding the items currently exempt from co-payments? Is there tracking by NYRx in place regarding waived co-payments?
Published: January 12, 2023
No. The same copay exemptions still apply. NYRx does not track point of service waived copays. More information on copayments including exemptions, payment collection and billing can be found in the Pharmacy Provider Manual (pages 41 & 42).
FAQ 141 Do pharmacists need to be enrolled as Medicaid providers to be reimbursed for vaccinations under NYRx?
Published: January 12, 2023No. The pharmacy must be enrolled in the NYS Medicaid program, and enrolled pharmacies are eligible for reimbursement of covered vaccination services.
FAQ 142 Will providers and members be informed of the medications in need of a Prior Authorization before implementation on April 1, 2023?
Published: January 12, 2023
Yes, members and providers will receive letters regarding non-preferred products recently utilized by the member. A one-time transition fill will be provided before prior authorization is required. For more information on the transition fill period please reference FAQ 051, FAQ 113, and FAQ 124.
FAQ 143 Does the NYRx pharmacy program require pharmacies to be enrolled in Vaccine for Children (VFC) program in order to provide vaccinations?
Updated: February 12, 2023
A pharmacy is not required to enroll in VFC, but New York State (NYS) Medicaid should never be billed for the cost of any vaccine for persons under 19 years of age when it is available through the VFC Program. The VFC program is currently enrolling pharmacies, for a New York City pharmacy refer to the New York City VFC Program, and outside of NYC, refer to the New York State VFC Program. Pharmacies that are not enrolled in the VFC program and choose to provide vaccines for children younger than 19 years of age, at no charge to the member or Medicaid program, can be reimbursed for the administration only. Please refer to the links below for more information:
FAQ 144 For members who receive oral enteral products, such as Ensure, with existing prior authorization (PA) from Managed Care Plans (MCPs), will prescribers need to obtain a new PA for these products?
Published: January 12, 2023
Providers will need to obtain a new prior authorization for oral enteral products. Please refer to the DME Provider Manual for more information (page 35).
FAQ 152 Who should providers contact for billing and payment support?
Published : February 17, 2023
Providers should direct billing and payment questions to the eMedNY Call Center at (800) 343-9000. For more information for pharmacy providers, please refer to the Pharmacy Quick Reference guide. Additional billing information can be found in the January 2023 Medicaid Update Special Addition Part Two.
FAQ 153 Will the transition fill apply to claims where the generic drug is submitted for a Brand Less Than Generic (BLTG) drug?
Published : February 17, 2023
No. Pharmacists can dispense brand name drugs subject to the BLTG program without prescriber intervention. For information on the BLTG program, please refer here.
FAQ 154 Will NYS DOH provide a listing of the types of point of service overrides that will be supported?
Published : February 17, 2023
The NYRx Pharmacy Provider Manual has guidance for override situations, including lost or stolen prescriptions (page 8) and obtaining Prior Authorization for 72-hour emergency supply (page 13). Please visit the Provider Manual for guidance on unlicensed residents, interns, and foreign physician in training programs (page 24), and Out-of-State (OOS) Licensed Prescribers (page 25).
For override guidiance on early fills pertaining to vacation or a temporary absence, please refer to the August 2021 Medicaid Update. For override guidiance on early fills pertaining to lost or stolen medication, please refer to the Provider Manual (page 8).
FAQ 165 For members that utilize a Managed Care Plan (MCP) as a medical provider, how will the Transition impact the use of telemedicine and telemedicine prescribers that are not enrolled in NYS Medicaid FFS?
Published: March 17, 2023
All Medicaid Managed Care (MMC) network furnishing, ordering, prescribing, referring and attending (OPRA) providers must be enrolled with New York State (NYS) Medicaid FFS, including telemedicine providers. Effective September 1, 2022, MMC Plans began to deny payment to unenrolled pharmacies, other unenrolled practitioners, and providers for services provided and/or prescribed. Providers servicing MMC members should, without delay, begin the enrollment process and complete all required forms, including certifications. Please refer to the April 2022 Medicaid Update article titled Medicaid Enrollment Requirements and Compliance Deadlines for Managed Care Providers.
FAQ 166 Will an existing prescription that was filled after 60 days from being written and is more than 180 days, still be able to be refilled? Will a prescription on file that has not been filled yet, and is over 60 days from the original prescribe date, will that be able to be filled?
Published: March 17, 2023
NYS Medicaid does not require a prescription to filled within 60 days of the date written. Effective June 24, 2021, prescriptions are valid and may be filled for up to one year from the date issued. After the prescription expires, new prescriptions will be required from prescribers, even when refills remain on the original prescriptions. Refill and PA allowance may be less based on the Federal Drug Administration (FDA) labeling and/or best practices.
FAQ 167 Does the OTC and Prescription Drugs Lookup Tool, known as the List of Medicaid Reimbursable Drugs, identify what the preferred/covered brand or manufacturer is? Or if the search tool shows that it is covered, should providers assume that any manufacturer available will be covered?
Published: March 17, 2023
The List of Medicaid Reimbursable Drugs has been established by the New York State Commissioner of Health. Only those prescription and non-prescription drugs which appear on the List are reimbursable under NYRx . The List also contains those nonprescription therapeutic categories which the Commissioner of Health has specified as essential in meeting the medical needs of Medicaid members. The entire List is available electronically.
There is a Search tool for OTC and Prescription Drugs Tool is designed for members to provide general information regarding drugs covered under the NYRx program.
FAQ 171 Can clinical staff submit prior authorizations as the agent of the prescriber, or are they required to become designated users?
Updated: October 1, 2024
The Prime Therapeutics clinical call center will utilize the NPI to verifying the identity of the presciber or their agent.
FAQ 172 If a Medicaid Managed care staff member is not a designated user, will they be able to access client specific information from Prime Therapeutics?
Updated: October 1, 2024
The Prime Therapeutics Education and Outreach (E&O) call center cannot discuss specific member concerns until they can verify a caller using NPI or a designated users IVN. The IVN is a number assigned by Prime Therapeutics for Medicaid Managed Care Plans (MCPs) only. The process to become a designated user is an internal process between the Department, Managed Care Plans, and Prime Therapeutics.
FAQ 173 Can a provider call on a member's behalf if the provider is receiving the rejection to "use primary coverage"?
Published: May 12, 2023
Yes, in emergency situations providers can contact the eMedNY call center at 1-800-343-9000. However, providers should direct members to their place of Medicaid enrollment to update their eligibility and request removal of any inactive coverage from their records. Please contact the Human Resource Administration (HRA) for New York City at (718) 557-1399 or the Medicaid Helpline (800) 541-2831. For Local District contact information please visit: New York State Local Departments of Social Services (LDSS) (ny.gov).
FAQ 174 How can providers assist members who are restricted to a specific provider or pharmacy obtain their medications?
Published: May 12, 2023
The Restricted Recipient Program (RRP) is an Office of the Medicaid Inspector General (OMIG) program. Providers and members can reach out to their Managed Care Plan (MCP) to find out who their restricted providers are. Additionally, members can contact their Local District to determine who their restricted providers are. For Local District contact information please visit: New York State Local Departments of Social Services (LDSS) (ny.gov). The upcoming Medicaid Update will include more information regarding the RRP and billing guidelines for restricted recipients.
FAQ 176 What is the NYRx Education and Outreach?
Updated: April 10, 2024
The Education and Outreach team serves as a liaison between the Managed Care Plans and NYRx to support care coordination. Clinical liaisons are trained to support and help solve complex pharmacy cases for:
- Managed Care Plans
- Case workers and New York State agencies
- Prescribers and pharmacies with questions regarding NYRx drug coverage, prior approval requirements, and NYRx enrolled pharmacies
- Complex care coordination for populations such as HIV/AIDS, Hemophilia, Foster Care children, Serious Mental Illness, Substance Use Disorder, and Hepatitis C
To contact the Education and Outreach team call (833) 967-7310. The call center is available Monday through Friday 8am until 5pm ET. NYRx program-related questions and non-member-specific questions can be emailed to NYRxEO@primetherapeutics.com.
For more information regarding NYRx Education and Outreach program information, resources and trainings/office hours please visit here: NYRx, the Medicaid Pharmacy Program | Education & Outreach (fhsc.com)
FAQ 177 If a member has Medicare and Medicaid, should providers allow those members to receive their medications without paying copays?
Published: June 20, 2023
Medicaid covers a limited benefit for dual eligible beneficiaries including select prescription vitamins, cough formulations and OTC products. There are no changes in the copay requirements, including the provider's responsibility to provide services when the member is unable to pay a copay. For information, please see the Pharmacy Manual (pages 44-46).
FAQ 178 Where can providers find a member’s Client Identification Number (CIN)?
Published: June 20, 2023
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.
A chart containing the CIN format for each MMC Plan ID card can be found in the New York State Medicaid Update - January 2023 Volume 39 - Number 2 (ny.gov). 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.
For more information regarding member eligibility checks refer to FAQ 134.
FAQ 194 Can residents, interns or foreign physicians, or physician assistants (PAs), not enrolled in Medicaid FFS, prescribe utilizing override codes or would a supervising, enrolled doctor need to resend the prescription?
Published: July 26, 2023
Yes, residents, interns, and foreign physicians can prescribe utilizing override codes under NYRx. Billing information and guidance for prescriptions written by residents, interns, and foreign physicians can be found in the May 2023 Special Edition Medicaid Update.
Physician Assistants, as well as Nurse Practitioners (NP), are required to enroll in the NYS Medicaid FFS program as either a billing provider or OPRA provider to prescribe to Medicaid members.
FAQ 195 When providers are experiencing issues with prior authorizations for DME supplies, specifically a prior authorization that has been processed and needs to be changed, who should providers contact for resolution?
Published: July 26, 2023
Please contact the NYS Medicaid DME team by email at ohipmedpa@health.ny.gov For assistance with specific questions on criteria or for claims processing and resources please contact eMedNY.
FAQ 196 Did NYRx inform providers and members of the medications that would require prior authorization following the pharmacy benefit transition on April 1, 2023?
Published: July 26, 2023
Yes, member and providers were notified prior to the transition that they or their patients were on a non-preferred drug. This notice encouraged providers to review the NYRx Preferred Drug List to become familiar with the NYRx pharmacy program and preferred drug list.
Claims Processing & Operations
FAQ 035 What claims adjudication system will be used when the pharmacy benefit is transitioned to the Fee-For-Service (FFS) program? Will claims be captured or reported as in the past or adjudicated as being done by the Managed Care Plans (MCPs)?
Updated: June 20, 2023
As the pharmacy benefit has transitioned to the Medicaid NYRx Pharmacy program on April 1, 2023, NYS DOH will use the eMedNY system for point-of-sale claims adjudication. This is the claims adjudication system which is currently used for Medicaid members that access all their benefits through the FFS program.
FAQ 036 Will the CoverMyMeds or Surescripts platforms still be able to be used for the prior approval process after the pharmacy benefit is transitioned to the Medicaid Pharmacy program, NYRx?
Updated: October 1, 2024
Providers can still leverage the CoverMyMeds platform via the PA fax process with Prime Therapeutics. Surescripts is not be available following April 1, 2023.
FAQ 055 Will NYS DOH implement a process to prevent duplicate billing of the same drug via the pharmacy benefit and the medical benefit through Managed Care Plans (MCPs)? For example: Vivitrol is available both through the pharmacy and medical benefit.
Published: September 4, 2020
NYS DOH will collaborate with the Office of the Medicaid Inspector General (OMIG) to develop processes to evaluate and address potential duplicate claims for drugs that are available through the pharmacy and medical benefit.
FAQ 060 As a result of the pharmacy benefit transition, will the 5-limit refill on medications be imposed? If so, will this exclude contraceptives?
Updated: July 8, 2022
The 5-limit refill rule on medications is no longer in place. Effective, May 1, 2021, prescriptions are valid and may be filled for up to one year from the date issued. Once the prescription expires, a new prescription from the prescriber would be required.
Contraceptives continue to be available for a one-year supply, per the November 2019 Medicaid Update Article, providing that the prescriber writes the prescription for a one-year supply.
FAQ 088 Will medical supply companies who do not have NYS Medicaid Pharmacy enrollment be able to bill the member's DME benefit for the respective product categories?
Updated: July 8, 2022
Medical supply companies enrolled in Medicaid Fee-For-Service (FFS) as a Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) provider can bill pharmacy supplies and procedures subject to the pharmacy benefit transition.
FAQ 089 Is NYS DOH prepared to handle the influx of Durable Medical Equipment (DME) claims from medical suppliers?
Updated: July 8, 2022
Yes. There is a plan in place for NYS DOH systems and call centers to have the capacity to manage the increased volume of claims and inquiries regarding DME/Supplies subject to the transition.
FAQ 114 How are NYS DOH call center staff, who are managing Prior Authorization approvals, prepared to ensure that they are culturally competent to prevent disruptions?
Published: October 12, 2022
NYS DOH will be utilizing existing call centers, in which processes are already in place that serve the current diverse population of NYS Medicaid members. Call centers are familiar with the needs of Medicaid members, have the skills and training to prevent disruption, and NYS DOH have prepared trainings in anticipation of new call center staff being added.
FAQ 135 For the transition period/fill, will there be an override providers should utilize to bill the prescription as a transition fill?
Published: December 14, 2022
No, the transition fill will be automatically adjudicated via the eMedNY claims processing system. There will be an approved response message sent alerting the pharmacy that the claim paid as a transition fill.
FAQ 136 How will Providers be supported with claim issues or questions on April 1, 2023, as it will be a weekend?
Updated: October 1, 2024
The claims processing call center has weekend hours currently. The Department has evaluated those hours and made adjustments as necessary. The Prime Therapeutics clinical call center is available 24/7. Program staff have monitored real-time claims over the course of the implementation.
FAQ 155 Will claims paid under the transition fill policy include the applicable NCPDP Approved Message Code (548-6F) value (e.g. 004, 005, 006, 007) to alert the pharmacy staff that the claim was paid under transition and the next fill will be at risk of a PA Required, Non-Formulary or Plan Limit reject?
Published: February 17, 2023
The eMedNY claims processing system will populate 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. Please refer to the January 2023 Medicaid Update Special Addition Part Two for more information.
FAQ 156 Will NYRx support returning a Paid (transaction response Code = P) with the required pricing fields to align with NCPDP Telecommunication Standard versus a Captured response?
Published: February 17, 2023
Claim capture is available. Transaction instructions are available on eMedNY.
FAQ 197 Education Law Article 137 does not allow a pharmacy to use Daw “9” for the NYRx Brand less than generic (BLTG) program, what should providers do in this situation?
Published: July 26, 2023
The Brand Less Than Generic (BLTG) Program is a cost containment initiative which 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. This program conforms with State Education Law, which intends that a patient receive the lower cost alternative. State Education Law does not specify DAW code values.
FAQ 198 How can claims be reversed? Can claims only be reversed by the pharmacy that submitted the claim in ePACES?
Published: July 26, 2023
Pharmacy claims can be reversed real-time. For real-time pharmacy transaction instructions please refer to the NCPDP Companion Guide. Providers must ensure that the claim is an ECCA claim and information regarding ECCA claims can be found here. Providers can also contact eMedNY for assistance.
Data Sharing
FAQ 056 Can NYS DOH provide context surrounding the data sharing implementation such as a testing plan, frequency of data sharing, data file layout/contents, and if the intention is for the data file to meet HEDIS requirements?
Updated: June 20, 2023
NYS DOH has provided a data claims file to the Managed Care Plans (MCP) beginning April 1, 2023. Through the Technical Workgroup, NYS DOH has collaborated with MCPs to obtain consensus on the data file that has been created.
FAQ 073 How will the pharmacy benefit transition impact the visibility of Managed Care Plans (MCPs) to member pharmacy claims? Will MCPs still have access to data on the member level?
Updated: June 20, 2023
The NYS DOH supplies a claims file to the Managed Care Plans (MCPs). Through the Technical Workgroup, NYS DOH has collaborated with MCPs to obtain consensus on the data file and data elements (e.g. member information) that are needed.
FAQ 104 How frequently will NYS DOH provide Managed Care Plans (MCPs) with pharmacy utilization data after the transition? How will NYS DOH ensure the data will be reliable?
Updated: June 20, 2023
NYS DOH has continued working with Managed Care Plans (MCPs) to ensure claims utilization data will be provided to the Medicaid MCPs daily, for the previous day's activity. Daily pharmacy utilization data sharing was previously tested and reviewed and tested in anticipation of the Pharmacy Benefit Transition implementation date, and MCPs have been receiving daily claims data beginning April 1, 2023.
FAQ 199 What quality assurance checks will be done to assess changes in medication adherence or hospital utilization? Have pharmacy claims been sent to Managed Care Plans?
Published: July 26, 2023
Care management continues to be the responsibility of the Managed Care Plans (MCPs). NYRx provides the MCPs daily claim information for clinical management and care coordination, as well as weekly medication adherence and first fill reports. The MCPs remain responsible for medical claims, including hospital claims. More information regarding MCPs roles and responsibilities can be found in the Pharmacy Benefit Transition roles and responsibilities document.
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