Scope of Benefits
- Scope of Benefits - also available in Portable Document Format (PDF)
Pharmacy Benefit Transition: The following charts provide additional context and information related to the Department's transition of the pharmacy benefit services from managed care to fee-for-service (FFS), effective April 1, 2023.
+CHART #1
This chart provides an inventory of the NYRx Medicaid Pharmacy Program’s outpatient pharmacy benefit. Health Plans (Managed Care Plans (MCPS)) should continue to make the benefit available when provided by a non-pharmacy provider.
| Pharmacy Benefit Category | Sub-Category | Covered by NYRx pharmacy benefit (Yes, No) | Covered by Health Plan (MCPs) medical benefit when billed as a medical or institutional claim (e.g., outpatient hospital, clinic, physician's office) * |
|---|---|---|---|
| Outpatient Prescription Drugs included in the Medicaid Pharmacy List of Reimbursable Drugs. (Includes Clotting Factor) | N/A | Yes | Yes ([for drugs that are also practitioner/physician administered (i.e. J-Codes)] |
| Practitioner/Physician Administered Drugs that are not included in the Medicaid Pharmacy List of Reimbursable Drugs. | N/A | No | Yes |
| Outpatient Over the Counter (OTC) Drugs included in the Medicaid Pharmacy List of Reimbursable Drugs. | N/A | Yes | No |
| Vaccines that can be administered by pharmacists ** COVID-19 Diagnostic Testing & Specimen Collection |
N/A | Yes | Yes |
| N/A | Yes | Yes | |
| Supplies as listed in the Pharmacy Procedures & Supply Codes, Manual and categorized below | Yes | No | |
| Enteral and Parenteral Nutrition Formula | Yes | No | |
| Enteral and Parenteral Feeding Supply Kit and Tubing | Yes | No | |
| Condoms and Diaphragms | Yes | No | |
| Incontinence Care – Under Pads, Diapers, Liners, Catheters and Accessories | Yes | No | |
| Adhesive Tape/Remover | Yes | No | |
| Antiseptics | Yes | No | |
| Commode Accessories- Bed Pans, Urinals, Sitz Baths | Yes | No | |
| Breast Pumps (except rental of hospital grade pumps) | Yes | No | |
| Blood Pressure Monitors | Yes | No | |
| Canes/Crutches and Accessories | Yes | No | |
| Diabetic Diagnostics and Daily Care- Glucose Testing Supplies, Disposable Insulin Pumps (Omnipod), Continuous Glucose Monitor (CGM), Insulin Syringes, Needles, Pens, Infusion Supplies | Yes | No | |
| Mastectomy Care - Mastectomy Bras, Breast Prosthesis (except custom prosthesis), Camisoles | Yes | No | |
| Respiratory/Tracheostomy Care Supplies | Yes | No | |
| External Urinary Supplies - Drainage Bags and Urethral Clamps | Yes | No | |
| Ostomy Supplies | Yes | No | |
| Wound Dressings | Yes | No | |
| Syringes | Yes | No | |
| Gloves | Yes | No | |
| Heat Application/Thermometers/Cold Wraps | Yes | No | |
| Surgical Stockings, Slings, Splints, Cervical Foam Collars | Yes | No | |
| Plastic Strips, Sterile Wood Applicators, Spirometers, Nasal Aspirators | Yes | No | |
| Disposable Drug Delivery Systems | Yes | No | |
| Sterile Water, Saline, and Dextrose | Yes | No | |
| N/A | Yes | No | |
Medical supplies dispensed during a Physician's Office visit and billed under CPT code 99070:
|
Examples are: crutches, boots or other starter medical supplies. | No | Yes |
| Durable Medical Equipment, Prosthetics, Orthotics, and Supplies as listed in the Durable Medical Equipment, Prosthetics and Supplies Manual and categorized within Appendix A. | N/A | No | Yes |
* For benefits marked as Yes, MCPs will continue to pay for these benefits for their members when they are not billed by pharmacies.
** In accordance with revised New York State Education laws, licensed pharmacists who obtain an additional certification are permitted to administer influenza vaccine to children between the ages of 2 and 18 years of age and to adults 18 years of age and older as recommended by the Advisory Committee on Immunization Practices (ACIP) of the Center for Disease Control and Prevention (CDC). The New York State Medicaid Fee-For-Service Program Pharmacists as Immunizers Fact Sheet contains current information and guidelines.
+Appendix A
This appendix provides a list of Durable Medical Equipment (DME) supplies that are not subject to the transition and are found within the Durable Medical Equipment, Prosthetics, Orthotics, Supplies and Procedure Codes and Coverage Guidelines. Within the Durable Medical Equipment, Prosthetics, Orthotics, Supplies and Procedure Codes and Coverage Guidelines, sections 4.1, 4.2, and 4.3 are subject to the transition while sections 4.4, 4.5, 4.6, and 4.7 will remain the responsibility of the Managed Care Plans. For convenience, the items that will not be subject to the transition are categorized and listed below. Please refer the Durable Medical Equipment, Prosthetics, Orthotics, Supplies and Procedure Codes and Coverage Guidelines for more specific guidance.
Medical/Surgical Supplies
- Hospital grade breast pump rentals
Durable Medical Equipment
- Hospital beds and accessories
- Oxygen systems
- Respiratory care supplies
- Ventilators and accessories
- CPAP/BiPAP devices and accessories
- Airway clearance devices and accessories
- Traction equipment
- Walkers
- Pediatric gait trainers
- Wheelchairs and accessories
- Powered mobility devices
- Power operated vehicles
- Miscellaneous Durable Medical Equipment:
- Paraffin bath unit and wax
- Apnea monitor and supplies-electrodes, lead wires
- Replacement battery for external infusion pump
- Commodes, bath/shower chairs, bathtub/toilet rails, raised toilet seats, tub stools/benches, transfer benches
- Seat lift mechanisms
- Automatic external defibrillator garment
- Vacuum erection system
- Artificial larynx, batteries, accessories
- Tracheostomy speaking valve
- Tracheo-esophageal voice prosthesis and gelatin capsules, voice amplifier
- Insert for indwelling tracheoesophageal prosthesis (replacement only)
- Tracheoesophageal puncture dilator (replacement only)
- Enuresis alarm
- Phototherapy lights
- Home standing systems
- TENS devices (including electrodes, lead wires, batteries), osteogenesis stimulators
- IV poles, ambulatory infusion pumps
- External ambulatory infusion pump, insulin
- Parenteral infusion pumps
- Hyperbaric oxygen chambers, negative pressure wound therapy
- Speech generating devices, accessories, and repairs
- Eye control/eye gaze accessories
- Servicing, parts, and repairs of Durable Medical Equipment
Orthotics
- Orthotic devices, additions, procedures, and repairs
Prescription Footwear
- Orthopedic footwear, additions, transfers, and replacements
- Diabetic shoes, fitting, and modifications
Prosthetics
- Prosthetics, procedures, and additions
- Breast and Hair prosthesis
- Custom breast prosthesis and mastectomy sleeve (mastectomy bras, camisoles, and non-custom breast prostheses will transition to FFS)
- Upper extremity elastic supports
- Lower extremity compression supports
- Trusses
- Prosthetic Socks
- Burn garments
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