Practitioner Administered Drug Additions to NYRx Formulary

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Updated August 2, 2023

NYS DOH recognizes the need for certain drugs requiring administration by a practitioner to be available through the Medical and Pharmacy Benefit. Practitioner administered drugs (PADs) that are listed on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page may be billed directly to the NYRx under the pharmacy benefit. PADs obtained by the practitioner, must be billed as a medical claim to the MMC Plan of the member. Please note this list is subject to change. NYRx provided temporary formulary coverage of select drugs noted in red.

Drug Name NDC Manufacturer Referenced
HCPCS Code		 NYRx Coverage
End Date
EVENITY 105 MG/1.17 ML SYRINGE 55513088001 AMGEN J3111 4/23/2023
EVENITY 210 MG DOSE-2 SYRINGES 55513088002 AMGEN J3111 4/23/2023
KANJINTI 150 MG VIAL 55513014101 AMGEN Q5117 4/23/2023
KANJINTI 420 MG VIAL 55513013201 AMGEN Q5117 4/23/2023
MVASI 100 MG/4 ML VIAL 55513020601 AMGEN J9035 4/23/2023
MVASI 400 MG/16 ML VIAL 55513020701 AMGEN J9035 4/23/2023
PROLIA 60 MG/ML SYRINGE 55513071001 AMGEN J0897 4/23/2023
TEZSPIRE 210 MG/1.91 ML SYRING 55513011201 AMGEN J2356 4/23/2023
XGEVA 120 MG/1.7 ML VIAL 55513073001 AMGEN J0897 4/23/2023
TRIPTODUR 22.5 MG KIT 24338015020 ARBOR/AZURITY J3316  
TYSABRI 300 MG/15 ML VIAL 64406000801 BIOGEN-IDEC J2323 4/23/2023
ABRAXANE 100MG VIAL 68817013450 CELGENE/BMS J9264 4/23/2023
INJECTAFER 100 MG/2 ML VIAL 00517060201 DAIICHI-SANKYO J1439  
INJECTAFER 750 MG/15 ML VIAL 00517065001 DAIICHI-SANKYO J1439  
OCREVUS 300 MG/10 ML VIAL 50242015001 GENENTECH, INC. J2350  
PERJETA 420 MG/14 ML VIAL 50242014501 GENENTECH, INC. J9306  
SUNLENCA 463.5 MG/1.5 ML VIAL 61958300201 GILEAD SCIENCES J3490  
BENLYSTA 400MG & 120 MG VIAL 49401010101;
49401010201		 GLAXOSMITHKLINE J0490 4/23/2023
REMICADE 100 MG VIAL 57894003001 JANSSEN BIOTECH J1745 4/23/2023
KEYTRUDA 100 MG/4 ML VIAL 00006302601;
00006302602;
00006302604		 MERCK SHARP & D J9271 4/23/2023
EYLEA 2 MG/0.05 ML SYRINGE 61755000501;
61755000554		 REGENERON PHARM J0178 4/23/2023
EYLEA 2 MG/0.05 ML VIAL 61755000502;
61755000555		 REGENERON PHARM J0178 4/23/2023
FENSOLVI 45 MG SYRINGE KIT 62935015350 TOLMAR PHARMACE J1951  
CRYSVITA 20 MG/ML VIAL 69794020301 ULTRAGENYX PHAR J0584 4/23/2023
CRYSVITA 30 MG/ML VIAL 69794030401 ULTRAGENYX PHAR J0584 4/23/2023
APRETUDE ER 600 MG/3 ML VIAL 49702023803;
49702026423		 VIIV HEALTHCARE J0739  
CABENUVA ER 400 MG-600 MG SUSP 49702025315 VIIV HEALTHCARE J0741  
CABENUVA ER 600 MG-900 MG SUSP 49702024015 VIIV HEALTHCARE J0741