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.

The State Medicaid Pharmacy Benefit Program, NYRx, issued guidance for billing of long acting injectables for mental health and substance abuse treatment.

For more information, please contact NACDS’ Ben Pearlman at 617-515-2603.

On March 27, the State Department of Secondary Education published the following emergency orders in the New York Register (March 27, 2024, Vol XLVI, Issue 13).  

• Pharmacist Dispensing Self-Administered Hormonal Contraceptives which was effective March 12, 2024, and 
• Administration of Injectable Medications by Pharmacists for the Treatment of Mental Health and Substance Use Disorder, effective April 1, 2024. 

Also in New York, the State Department of Health also issued a billing guidance on issuance of hormonal contraceptives. For NYRx billing, see below:  

• To bill for the self-administered hormonal contraception, the pharmacy must submit a valid National Drug Code (NDC). Pharmacies must bill the Usual and Customary (U&C) price and will be reimbursed according to NYRx payment methodology and a $10.18 dispensing fee.
• To bill for the evaluation and management associated with the ordering of self- administered hormonal contraception, pharmacies will submit using the National Council for Prescription Drug Programs (NCPDP) D.0 claim format and enter one of the Healthcare Common Procedure Coding System (HCPCS) codes identified below. 
• NYRx members may receive up to 12 months of prescription contraceptives at one time for family planning purposes as authorized by the Title 18 NYCRR Section 505.3(e). 
• Pharmacies are expected to dispense up to the quantity limit of the prescription or Standing Order, one year supply, at the time of dispensing, pursuant to patient preference or primary insurance coverage limitations.
• Submitting any assessment code more than once a year requires cause.

For more information, please contact NACDS’ Ben Pearlman at 617-515-2603.

On March 19, the State Department of Health Commissioner signed a standing order regarding the new law authorizing pharmacist dispensing of hormonal contraception. The standing order signed by the State Health Commissioner pertains to three types of self-administered hormonal contraceptives that are approved by the federal Food and Drug Administration to prevent pregnancy, which include the following:  

• Oral hormonal pill  
• Hormonal vaginal ring  
• Hormonal contraceptive patch  

Pharmacists who choose to participate can dispense up to 12 months of a self-administered hormonal contraception of the individual’s preference and covered under insurance. 

Also in New York, the Office of Health Insurance Programs of the State Department of Health has approved the release of the February 2024 Medicaid Update. The update includes:  

Pharmacy: 

• Reminder: Pharmacies Submitting Medicaid 340B Drug Claims (Cover)  
• Reminder: Pharmacy Coverage Includes Over the Counter Naloxone 

Policy and Billing: 

• Update for Long-Term Care Pharmacy Providers on Short Cycle Billing of Pharmacy Claims 

For more information, please contact NACDS’ Ben Pearlman at 617-515-2603.

On March 5th, the NYRx Clinical Call Center reported that they are experiencing higher than normal call and fax volume. Prescribers should not send duplicate prior authorization (PA) requests to NYRx. Prescribers may experience a higher volume of requests for PA, but only one submission is necessary. Pharmacies should only request one PA for each member for each drug. Duplicate requests slow down the processing time at the NYRx Clinical Call Center. For more information, refer to NYRx Notice to Providers: Duplicate Prior Authorization Requests. To review how to submit a PA to NYRx, refer to the NYRx Prior Authorization Submission Guide. 

Enhancements have been made to the NYRx clinical criteria system editing. The clinical criteria have not changed and should be reviewed on the NYRx Preferred Drug List prior to obtaining a PA. Preferred products should be prescribed when clinically appropriate. In most cases, preferred products will not require a PA when prescribed according to FDA (FOOD AND DRUG ADMINISTRATION) labeling. To review NYRx preferred products only, refer to the NYRx Preferred Drug Quick List. 

For more information, please contact NACDS’ Ben Pearlman at 617-515-2603.

On February 27, the State Department of Health Office of Health Insurance Programs approved the release of the January 2024 Medicaid Update.  

• eConsults (Cover) 
• NY State of Health Public Health Emergency Unwind Fact Sheet for Providers Now Available 

• Zynteglo® (betibeglogene autotemcel): Medicaid Practitioner Administered Drugs Update 
• Reminder: New York State Medicaid Covers Nirsevimab, Abrysvo and Arexvy for the Prevention of Respiratory Syncytial Virus 
• Updated Fees for Family Planning Services 
• Medicaid Managed Long Term Care Transportation Carve Out Begins March 1, 2024 

Also in New York, the State Board of Pharmacy will be holding its regular meeting on March 7 at 10:00 am in New York City. The Board advises that members of the public wishing to observe the Board of Pharmacy’s public session must email their full name to the Pharmacy Board office (pharmbd@nysed.gov) at least 48 hours in advance. Failure to notify the Board office may result in delayed entry to the meeting. For security purposes, a valid Government issued ID will be required for admittance. 

Also in New York, S8545, was introduced last week at the request of NACDS and the Community Pharmacy Association of New York State. This legislation would (1) remove the limitation on where “registered pharmacy technicians” can practice in the state to all pharmacy settings; (2) add vaccine administration authority to the duties of registered pharmacy technicians; and (3) provide greater flexibility in the supervision standard for pharmacists overseeing registered pharmacy technicians from a “direct personal supervision” standard to being immediately available. An Assembly companion bill will be introduced soon.  

Also in New York, on February 13, the State Department of Health issued a new non-patient specific prescription for naloxone with pharmacy dispensing protocol effective February 13, 2024, through February 12, 2026.  

Finally in New York, the State has expanded its existing efforts at monitoring and understanding prescription drug prices by enacting legislation addressing prescription drug price transparency. Effective June 19, 2024, S599-A/A1707 amends the New York Insurance Law to require prescription drug manufacturers to report certain price increases before they occur. 

For more information, please contact NACDS’ Ben Pearlman at 617-515-2603.

On February 21, NYRx, the New York State Medicaid Pharmacy Benefit Program, held its monthly pharmacy sector meeting. On the agenda were the following:  

1. AIDS Institute – HCV (hepatitis C virus) drugs & test to treat model. 
   1. DOH (Department of Health) asked the following of pharmacies: 
      1. Does your pharmacy stock hepatitis C medications? How long does it take to get in stock? 
      2. How can we get medications in the client’s hands more quickly? 
      3. How can providers build collaborations with their local pharmacies to ensure timely access to hepatitis C medications? 
      4. How have you worked with hepatitis C providers in your community? 
      5. Feedback can be shared with Colleen Flanigan (colleen.flanigan@health.ny.gov) 

1. OMIG (Office of the Medicaid Inspector General) Pharmacy Audit Protocols. 
   1. OMIG utilizes a stakeholder process for updated regulations that includes feedback from DOH and professional associations. OMIG reviews and considers all comments that are submitted before issuing a revised protocol set.  
   2. Bill Schwarz with OMIG added that updated protocols are in development. Feedback may be shared at information@omig.ny.gov. 

1. Bureau of Medical Review – Incontinence Supplies. 
   1. Incontinence products claims have doubled since 2019 and require a valid diagnosis code that directly relates to incontinence for reimbursement. 
   2. Incontinence products info can be found in the DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics and Supplies) Procedure Manual. 
   3. Starting in April, the DME (Durable Medical Equipment) Procedure Manual will be updated with a separate pharmacy manual. DMPOS Procedure Manual will contain everything that Managed Care Plans are still responsible for.  
   4. Questions: OHIPMedPA@health.ny.gov (1-800-342-3005) 

For more information, please contact NACDS’ Ben Pearlman at 617-515-2603.

NYRx, the New York State Medicaid Pharmacy Benefit Program, announced an update to its Brand Less Than Generic program (BLTG). Advair HFA® and Advair Diskus® are subject to the NYRx BLTG. In December 2023, due to market availability issues, NYRx temporarily allowed for generic Advair HFA® and Diskus® to adjudicate without prior authorization (PA) if the brand product was not available from the pharmacy’s wholesaler. The manufacturer has confirmed that Advair HFA and Diskus supply issues have resolved, and pharmacies will be able to obtain the supply needed for their NYRx members. Effective February 28, fluticasone/salmeterol HFA and Diskus (generic Advair) will once again require PA.

Also in New York, in conformance with State Education Law, a pharmacist shall dispense a less expensive, therapeutically equivalent drug containing the same active ingredients, dosage form and strength as the drug prescribed/ordered. This includes substituting the brand name drug when NYRx has determined it to be the less expensive alternative for the patient. Brand name drugs included in this program: 

• Do not require “Dispense as Written” (DAW) or “Brand Medically Necessary” on the prescription. 
• Have a generic copayment. 
• Are paid at the Brand Name Drug reimbursement rate or usual and customary price, whichever is lower (SMAC/FUL are not applied). 
• Do not require a new prescription if the drug is removed from this program. 

 Also in New York, Sen. Jeremy Cooney (D) introduced a bill, S8545, that authorizes registered pharmacy technicians to administer the same immunizations as licensed pharmacists under direct supervision of such licensed pharmacist. NACDS, in conjunction with the Community Pharmacy Association of New York State, will continue to support the bill and encourage passage this session. 

Finally in New York, Gov. Kathy Hochul (D) signed S8096, a bill that relates to the effective date of the self-administered hormonal contraceptive prescribing authority for pharmacists. The new law changes the effective date of the 2023 law from eighteen months from enactment to January 1, 2024.  

For more information, please contact NACDS’ Ben Pearlman at 617-515-2603.

On February 6, the Department of Financial Services posted updated, proposed regulations on PBMs. NACDS is reviewing the regulations and will get analysis out to members as soon as possible.  

Also in New York, NACDS will be participating in the Community Pharmacy Association of New York State lobby day on February 13 in Albany. On the agenda is advocacy for test and treat legislation, budget sections that impact Medicaid reporting, inspector general audit rules and other scope expansion.  

For more information, please contact NACDS’ Ben Pearlman at 617-515-2603.