Welcome to NYRx, the Medicaid Pharmacy Program

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The New York State Medicaid Pharmacy program, NYRx, covers medically necessary FDA approved prescription and non-prescription drugs for Medicaid members. Prescription drugs require a prescription order with appropriate required information. Non-prescription drugs, often referred to as Over-the-Counter or OTC drugs, require a fiscal order (a fiscal order contains all the same information contained on a prescription). Certain drugs/drug categories require the prescribers to obtain prior authorization. Information on this benefit can be found in the New York State Medicaid State Plan Amendment.

Beginning April 1, 2023, Medicaid members enrolled in mainstream Managed Care (MC) plans, Health and Recovery Plans (HARPs), and HIV-Special Needs Plans (SNPs) will have their pharmacy benefits transitioned to NYRx, the Medicaid Pharmacy program. The transition will not apply to members enrolled in Managed Long-Term Care plans (e.g., PACE, MAP, and MLTC), the Essential Plan, or Child Health Plus.

Pharmacy program and billing policy and other pharmacy related information can be found in the NYS MMIS Pharmacy Provider Manual and the Department's Medicaid Update. You may also contact us at NYRx@health.ny.gov or (518) 486-3209 for Medicaid pharmacy policy related questions.

For more information and copies of letters sent to pharmacists and prescribers, please see Pharmacy Provider Communications below.

The following information may be of interest to pharmacists and prescribers:

  • Brand Less Than Generic Program (BLTG)
    The Brand Less than Generic Program is a cost containment initiative which promotes the use of certain multi-source brand name drugs when the cost of the brand name drug is less expensive than the generic equivalent.
  • Clinical Drug Review Program (CDRP)
    The Clinical Drug Review Program (CDRP) is aimed at ensuring specific drugs are utilized in a medically appropriate manner.
  • Drug Utilization Review Program (DUR)
    Drug utilization review programs help to ensure that prescriptions for outpatient drugs are appropriate, medically necessary, and not likely to result in adverse medical consequences.
  • Emergency Services Only Pharmacy Coverage
    This page contains a non-inclusive list of oral or self-administered drugs for Emergency Medicaid Services Only members when prescribed for a sudden and acute emergency medical condition.
  • Formulary File/List of Reimbursable Drugs (external link)
    This page contains drug information from the pharmacy file. The full list of reimbursable drugs may be viewed online or downloaded. Only those prescription and non-prescription drugs which appear on the list are reimbursable under the fee-for-service Medicaid Pharmacy Program.
  • Foster Care
    Effective July 1, 2021, the Foster Care Drug Carve-Out List will no longer apply and members will access the pharmacy benefit via the managed care plan, or Medicaid Fee For Service, depending on enrollment status.
  • Mandatory Generic Program (external link)
    With the exception of drugs subject to the Preferred Drug Program or the Dispense Brand when Less than Generic program, State law excludes Medicaid coverage of brand name drugs when the Federal Food and Drug Administration (FDA) has approved a generic product, unless a prior authorization is received.
  • Medication Assisted Treatment (MAT) Formulary
    Under this statewide formulary, Medicaid Fee for Service and Managed Care members follow a single formulary with consistent coverage parameters across the Medicaid Program, and prior authorization is not required for medications used for the treatment of substance use disorder when prescribed according to generally accepted national professional guidelines for the treatment of a substance use disorder.
  • Medicaid Redesign homepage
  • Medicare Part D Prescription Drug Benefit
    Medicare Part D is a prescription drug benefit available to everyone with Medicare. It has special importance to people with Medicare and New York State Medicaid because Medicare Part D replaces Medicaid in paying for most prescription drugs.
  • Pharmacists as Immunizers
    In accordance with revised New York State (NYS) Education law, effective January 31, 2022, pharmacists certified to administer immunizations are authorized to administer to patients 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).
  • Pharmacy Benefit Transition
    Beginning April 1, 2023, Medicaid members enrolled in mainstream Managed Care (MC) plans, Health and Recovery Plans (HARPs), and HIV-Special Needs (SNPs) will receive their pharmacy benefits through the Medicaid Fee for Service (FFS) Pharmacy Program.The transition will not apply to members enrolled in Managed Long-Term Care plans (e.g.,PACE, MAP, and MLTC), the Essential Plan, or Child Health Plus.
  • Pharmacy Reimbursement Methodology (PDF)
  • Preferred Diabetic Supply Program (PDSP)
    The New York State Medicaid Program participates in a Preferred Diabetic Supply Program (PDSP) to provide New York State Medicaid enrollees access to quality glucose meters and test strips, while at the same time reducing overall program costs.
  • Preferred Drug Program PDP)
    The Preferred Drug Program (PDP) promotes the use of less expensive, equally effective prescription drugs when medically appropriate. All drugs currently covered by Medicaid remain available under the PDP and the determination of preferred and non-preferred drugs does not prohibit a prescriber from obtaining any of the medications covered under Medicaid.

Practitioner Dispensed Drug Policy and Billing Guidance

  • Medicaid reimburses all prescribing practitioners for drugs dispensed to Medicaid patients and members may obtain their oral medications through their physician's office. This includes patients receiving oral cancer medication from their oncologist.
  • NYSDOH Fee-For-Service expanded medical billing so that practitioners can use the existing medical claims format to be reimbursed for drugs furnished to Medicaid patients. This expands access so that practitioners serving Medicaid Managed Care and Fee-For-Service patients can use the same claims format. Medical billing ensures all practitioners can provide services to Medicaid patients and be reimbursed for services aligned with their enrollment and billing procedures.
  • Please see New York State Medicaid Update. (2022, July), article titled, Policy Clarification for Practitioner Dispensing, 38(8) pp. 8-9.