On July 17, 2024, NYRx, the State Medicaid Prescription Drug Program, hosted its monthly pharmacy call. The agenda included:

1. Pharmacy Reimbursement & Dispensing Fee Calculations
2. Pharmacy Enrollment: Pharmacies Pending Medicare Part B Revalidation
3. Vaccine Billing

The next call will be August 21, 2024.

Also in New York, the Office of Health Insurance Programs of the State Department of Health has approved the release of the June 2024 Medicaid Update. It included the following:

• Reminder: Licensed Providers Must Enroll with State Medicaid to Serve Medicaid Members
• Attention Pharmacy Providers: Cold Storage Requirement

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

NYRx, the State Medicaid Prescription Drug Program, posted a Pharmacy Prior Authorizations Programs Update. This update is effective August 1, 2024.

Also in New York, the Office of Health Insurance Programs of the State Department of Health has approved the release of the May 2024 Medicaid Update. This update includes a pharmacy reminder that Medicaid providers are required to bill applicable third parties that may be liable for a claim before billing Medicaid. Medicaid is always the payor of last resort and federal regulations require that all other available resources be used before Medicaid considers payment.

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

The State Department of Health released a notice of reminders to pharmacy providers in case of severe weather events.  These include drug storage, vaccines for children, drug delivery and NYRx prior authorizations.

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

NYRx, the Medicaid Pharmacy Benefit Program, announced updates to the Preferred Drug List. These changes were effective May 29. 

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

On May 21, the Senate Committee on Higher Education reported favorably S9186, a bill to update shared pharmacy services. The bill will establish conditions under which resident or non-resident pharmacists and pharmacies may participate in shared pharmacy services. S9186 has previously passed the Assembly. NACDS will continue to advocate for final passage of the bill in the Senate.

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

On May 15, 2024, the State Department of Health held its monthly NYRx, the Medicaid pharmacy benefit program, call for stakeholders in the pharmacy community. The agenda included a wrap up of the state budget, update to over-the-counter COVID-19 testing and pharmacy claims edit.  

On May 15, 2024, A9729, a bill related to shared pharmacy services, was approved by the Assembly. Under the bill, “shared pharmacy services” means a system that allows a registered pharmacist or a registered pharmacy, pursuant to a request from another registered pharmacist or pharmacy to process or fill a prescription or order, pursuant to regulations promulgated by the Commissioner of Education. The bill now moves to the Senate where we expect action. NACDS will continue to advocate for the bill’s passage.

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

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.