Medicaid Pharmacy Program
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Medicaid Fee-for-Service (FFS) Emergency Services Only Coverage
Medicaid FFS does not reimburse all covered drugs for patients whose coverage is deemed as "Emergency Services Only," category of eligibility (COE) 07.
Medicaid coverage may be available for care and services that are necessary for the treatment of an emergency medical condition. In accordance with federal regulation 42 CFR 440.255 (c), Medicaid coverage is available for emergency services (including emergency labor and delivery) required after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
- placing the patient´s health in serious jeopardy;
- serious impairment to bodily functions; or
- serious dysfunction of any bodily organ or part.
The following is 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 as defined above. Drugs are not covered for Emergency Medicaid Services Only members when used as maintenance for a chronic condition.
Covered
- ☒ Acute/short term
- Drugs prescribed and dispensed for an Emergency Medicaid Member under the NY Medicaid Program should only be sufficient to treat the sudden and acute emergency medical condition. An acute condition is a medical condition that has a fast onset and short duration.
Not Covered
- ☒ Chronic/maintenance
- Drugs prescribed or administered for a chronic medical condition or is taken as maintenance such as, on a regular consistent basis, are not allowable under this COE. A chronic medical condition is one that progresses slowly and generally long in duration.
Drugs are not covered to treat HIV/AIDS under Emergency Services Only Category of Eligibility, this is covered by the HIV Uninsured Care Programs (ADAP), information can be found here.
- Drugs prescribed or administered for a chronic medical condition or is taken as maintenance such as, on a regular consistent basis, are not allowable under this COE. A chronic medical condition is one that progresses slowly and generally long in duration.
- ☒ Prophylactic & suppressive treatment
- Drugs prescribed or administered for a prophylaxis or suppressive treatment are not covered under this COE.
The following drug list is also subject to the NY State Medicaid Fee for Service Pharmacy Programs criteria, information can be found here or by calling Magellan Call Center at 1-877-309-9493.
Drugs not on this list will reject with NCPCP code 70 which is defined as "drug not covered."
Pharmacies should not submit claims for ESO members for chronic, maintenance, prophylactic or suppressive use of the medications on this list. Prescribers seeking exception to this policy or for a drug not on this list may send a letter of necessity and supporting documentation via encryption to NYRx@health.ny.gov.
Submission of such a request does not guarantee approval. Exception/override requests for chronic, maintenance, prophylactic or suppressive use or drugs systematically denied for this category of service MUST be formally approved by the Department of Health (DOH). If request is determined coverable, the dispensing pharmacy will receive a DOH letter specific to the member, drug, and timeframe of approval.
Please note that obtaining a clinical PA from the Magellan Call Center does not supersede the requirement to obtain approval from NYS Medicaid for chronic use or a drug not included on this list.
| DRUG LIST FOR EMERGENCY SERVICES ONLY* |
|---|
| 1ST GENERATION CEPHALOSPORINS |
| 2ND GENERATION CEPHALOSPORINS |
| 3RD GENERATION CEPHALOSPORINS |
| AMEBICIDES |
| ANALGESICS, SHORT ACTING, prescribed for severe pain only |
| ANTIFUNGALS |
| ANTHELMINTICS |
| ANTIMALARIALS |
| ANTIMYCOBACTERIALS |
| ANTI-TRICHOMONAL / TRYPANOSOMALS |
| ANTIVIRALS-OTHER THAN FOR HIV |
| EXTENDED SPECTRUM PENICILLIN |
| FLUOROQUINOLONES |
| MACROLIDES / LINCOSAMIDES |
| MISC. ANTIBACTERIALS |
| MISC. ANTIDOTES / ANTAGONISTS - Opioid Antagonists |
| MISC CARDIO / RENAL AGENT (drugs indicated for and prescribed to patients with end stage renal disease (ESRD) on dialysis only) |
| MISC. HEMOSTATIC AGENTS (drugs indicated for and prescribed to patients with end stage renal disease (ESRD) on dialysis only) |
| MISC ANTIDOTES / ANTAGONISTS - Non Opioid Antagonists (drugs indicated for and prescribed to patients with end stage renal disease (ESRD) on dialysis only) |
| NARCOTIC AGONIST ANALGESICS - SHORT ACTING |
| NARCOTIC AGONIST / ANTAGONIST |
| NON-NARCOTIC / NARCOTIC COMBOS-SHORT ACTING |
| OPHTHALMIC ANTIBIOTICS/ANTIFUNGALS/ANTIVIRALS |
| OXAZOLIDINONE ANTIBIOTICS |
| PARENTERAL ANTICOAGULANTS/ANTAGONISTS |
| PENICILLIN |
| PENICILLINASE RESIST. PENICILLIN |
| SCABICIDES/PEDICULICIDES |
| SHORT ACTING BETA AGONIST- INHALER - for a specific sudden onset emergency medical event, acute use only |
| SHORT ACTING BETA AGONIST- NEBULIZER - for a specific sudden onset emergency medical event, acute use only |
| SULFONAMIDES ORAL |
| SYMPATHOMIMETIC-INJECTABLE |
| SYMPATHOMIMETIC-ORAL |
| TETRACYCLINES ORAL |
| URINARY ANTI-INFECTIVES |
| VITAMIN D (drugs indicated for and prescribed to patients with end stage renal disease (ESRD) on dialysis only) |
| Revised December 1, 2023 |
*When dispensed for acute use only unless otherwise specified for ESRD on dialysis.
Questions regarding this policy may be referred to phone 518-486-3209, or email NYRx@health.ny.gov.
