On April 17, 2024, NYRx, the New York State Medicaid Pharmacy Benefit Program, held its monthly call for pharmacy providers. On the agenda were long-acting injectable administration, COVID-19 anti-virials, self-administered hormonal contraceptives and Extencilline coverage. Questions and Additional Information:
- NYRx claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
- NYRx Pharmacy coverage and policy questions should be directed to the NYS Medicaid Pharmacy Policy Unit by telephone at (518) 486-3209 or by email.
Billing guidelines for Long-Acting Injectable administration:
Pharmacies will be reimbursed for the medication and an administration fee when billed to NYRx. The member will not have a copayment for drug administration.
- NYS legislation requires a patient specific prescription or order for administration. These orders must be kept on file at the pharmacy.
- If billing for both the drug and administration, these claims must be submitted separately.
- For the drug, the claim must be submitted using the ordering prescriber’s NPI in the Prescriber ID field. The pharmacy will be reimbursed for the medication when billed via National Drug Code (NDC) using reimbursement methodology. For the administration, the claim must be submitted using procedure code 96372, and the pharmacy’s NPI in the Prescriber ID field. A pharmacy will be reimbursed the administration fee of $13.36.
New York State Medicaid has also notified pharmacies that in response to the ending of the COVID-19 public health emergency on May 11, 2023, effective May 13, 2024, a fiscal order is not required for the first two tests per month. Furthermore, pharmacy reimbursement and covered products available on the pharmacy formulary will be modified. Additional tests may be covered with a fiscal order, when medically necessary. Coverage will be provided for OTC FDA-authorized COVID-19 test kits used in accordance with the Centers for Disease Control and Prevention (CDC) recommendations for antigen detection. This policy for coverage of at-home test kits via NYRx, the NYS Medicaid Pharmacy Program, will remain in effect until further notice.
If a member needs more than two (2) tests per month, and all other resources were utilized, and the member has a fiscal order, the pharmacy may call the Pharmacy Policy unit at 518-486-3209 for a review of medical necessity.
For more information, please contact NACDS’ Ben Pearlman at 617-515-2603.
