New York State Medicaid Update - September 2012 Volume 28 - Number 10

In this issue…

Policy and Billing Guidance

Mandatory Medicaid Managed Care Expanding to Additional Counties

Beginning in October 2012, managed care enrollment will be required for most Medicaid beneficiaries residing in Jefferson, Lewis, St. Lawrence, and Warren Counties. Once a mandatory managed care program is implemented in a county, it is expected that the enrollment of all eligible Medicaid beneficiaries will take up to twelve months to complete. Current Medicaid Managed Care Health Plan choices available in these counties include:

  • Jefferson: Excellus Health Plan, United Healthcare Plan of NY
  • Lewis: Excellus Health Plan, NYS Catholic Health Plan (Fidelis Care)
  • St. Lawrence: Excellus Health Plan, NYS Catholic Health Plan (Fidelis Care)
  • Warren: NYS Catholic Health Plan (Fidelis Care), United Healthcare Plan of NY

Providers should check the Medicaid Eligibility Verification System (MEVS) prior to rendering services to determine Medicaid eligibility and the conditions of Medicaid coverage. Providers are strongly encouraged to check eligibility at each visit as eligibility and enrollment status may change at any time. If the Medicaid beneficiary is enrolled in a Medicaid managed care plan, the first coverage message will indicate "Eligible PCP".

MEVS responses no longer include scope of benefits information so providers will need to contact the health plan to determine what services the plan covers. Service Type codes will be used to identify carved-out services where possible. Medicaid will not reimburse a provider on a fee-for-service basis if a medical service is covered by the plan.

For more information on MEVS messages, please see the February 2011 Special Edition Medicaid Update article at:

Providers may call the eMedNY Call Center at (800) 343-9000 with any Medicaid billing issues. Medicaid beneficiaries may call NY Medicaid Choice at (800) 505-5678 or contact their local department of social services (LDSS) to learn more about managed care.

For additional information on managed care covered services and managed care plan types, please see the December 2010 Medicaid Update article entitled "Managed Care Covered Services" at:

Mandatory Enrollment Plan for Managed Long-Term Care and Care Coordination Models Receives CMS Approval

The New York State Department of Health (NYSDOH) continues to move toward a fully integrated care management system for all individuals receiving long-term care services under the Medicaid program. Medicaid Redesign Team Initiative #90, the transition and enrollment of certain community-based long-term care services recipients into Managed Long Term Care Plans (MLTCPs) or Care Coordination Models (CCMs), is a major component of this transformation. Currently, New York State offers three models of MLTCPs: Program of All-Inclusive Care for the Elderly (PACE); Medicaid Advantage Plus (MAP); and partial capitated managed long-term care plans. Currently there are no CCMs established. All models provide community-based long-term care services, nursing home care, ancillary and supportive services, including care management.

In July 2012, the Department received verbal approval from the Centers for Medicare and Medicaid Services (CMS) to initiate mail distribution of mandatory enrollment notifications. These notifications, alerting current recipients that they must choose a Plan to continue receiving community based long-term care services, are being rolled out in New York City using a phased approach by borough and zip code. The recipient's prior authorization and Medicaid certification will remain intact through the transition to mandatory enrollment. The notifications urged recipients to contact the Department’s Enrollment Broker, New York Medicaid Choice, for information on joining a Plan. New York Medicaid Choice is available to assist with information on Plan services and can provide recipients with information on networks including home care agencies and other providers.

On August 31, 2012, the Department received written approval from CMS to proceed with auto-assignment of recipients into partial capitated managed long term care plans in New York City. The first group of Medicaid beneficiaries that received a mandatory notice that have not chosen a Plan, will receive an October 2, 2012 letter indicating the name of the Plan they are assigned to effective November 1, 2012.

The mandatory enrollment initiative will continue within the five boroughs of New York City until all eligible cases are transitioned. In January 2013, the initiative will move to Nassau, Suffolk and Westchester counties.

Questions? Please contact the Bureau of Managed Long Term Care via e-mail at:

New York Medicaid Electronic Health Records Incentive Program Update

The Department is pleased to announce that as of September 14, 2012, the New York Medicaid Electronic Health Records (EHR) Incentive Program has now paid over $181 million in federal incentive funds to over 2,600 New York State hospitals and healthcare practitioners.

The Department is continuing to review applications for Payment Year 2011 incentive payments that were submitted prior to the April 29, 2012, deadline, and applications for Payment Year 2012 are currently being accepted from providers who are new to the incentive program. Applications for providers’ second incentive payment (including Meaningful Use Attestation) will be accepted starting in the fourth quarter of calendar year 2012.

If you have not yet registered for the NY Medicaid EHR Incentive Program, we encourage you to visit the website ( or attend one of the informational webinars hosted by the NYS Department of Health throughout the month of October

Wednesday, Oct.3 3:00-4:00PM EP Participation Year 1 (A/I/U)
Thursday, Oct.4 12:00-1:00PM Program Prerequisites
Tuesday, Oct.9 10:00-11:00AM EP Support Documentation
Thursday, Oct. 11 10:00-11:00AM EP Participation Year 2 (MU)
Wednesday, Oct. 17 10:00-11:00AM EP Participation Year 1 (A/I/U)
Tuesday, Oct. 23 12:00-1:00PM Program Prerequisites
Thursday, Oct. 25 10:00-11:00AM EP Support Documentation
Wednesday, Oct. 31 12:00-1:00PM EH Participation Year 2 (MU)

The webinar schedule is subject to change based on interest levels. To view the complete schedule or to register for one of the webinars, please view the webinar schedules posted on the website:

Current Month:

Next Month:

Transportation Management Initiative Covers All New York City Boroughs

As of October 1, 2012, the Department and its contractor LogistiCare Solutions will implement non-emergency medical transportation management services for New York City Medicaid fee-for-service enrollees (i.e., those not in a managed care plan) who are receiving Medicaid covered services in Staten Island. LogistiCare is currently managing non-emergency transportation services in Brooklyn, Queens, Manhattan and Bronx.

All trips must be pre-arranged and confirmed by LogistiCare:

  • Requests for routine services must be pre-arranged 72 hours (3 days) in advance.
  • Requests for urgent (same day or next day) care are arranged any time.
  • Internet initiated and faxed requests for transportation must be sent to LogistiCare no later than 72 hours prior to the appointment to ensure sufficient time for processing.

Key Transportation Telephone Numbers

Medical Facility Services
877-564-5925 Monday - Friday
7a.m. - 6p.m.
The number the medical provider (you) can call to speak to one of LogistiCare's specialists to request standing order, episodic, urgent care trips, and those requests less than 3 days from the day of request.
Medical Facility Services Department fax 877-585-8758 (Brooklyn)
877-585-8759 (Queens)
877-585-8760 (Manhattan)
24/7 The number case managers or social workers fax the 2015 Medical Justification Form or the Standing Order Request forms to this number.
Hospital Discharge 877-564-5926 24/7 The number to ensure that hospital discharges are handled quickly and efficiently.
"Where's My Ride" 877-564-5923 24/7 The number if there is a service issue or complaint, or when the enrollee needs to be picked up.
Reservation Number for Enrollee Use 877-564-5922 Monday - Friday 7a.m. - 6p.m. The number a Medicaid fee-for-service enrollee can call to request transportation.

Transportation Management Implementation Schedule for Rest of City

Managed Care Plan Members
(other than long term care plans members)
January 1, 2013

Can Enrollees Request Transportation to Medical Appointments?

Medicaid members are now allowed to request their own trips to and from their medical practice. This may relieve providers of the administrative task of arranging every trip.

Prior to May 2012, providers were required to arrange every Medicaid enrollee's livery, ambulette and stretcher transport. Now, all that is required is the Medicaid Transportation Justification Request (Form 2015) to document the need for transportation via livery, ambulette and ambulance. This document is maintained by LogistiCare. When your patient requests a trip, we will verify the necessary mode and assign your preferred transportation provider to the appointment.

If the documentation is not on file, LogistiCare will contact you directly and ask you to submit the Medicaid Transportation Justification Request.

This form, along with all other forms and policy material, is available online, at The form may be saved electronically, and maintained as part of your electronic record. Questions for LogistiCare may be e-mailed to

Questions regarding this article may be e-mailed to, or via telephone at (518) 473-2160.

Medicaid Reimbursement for Immunizations Provided in Article 28 Hospital-Based & Freestanding Clinic Settings

The purpose of this article is to notify Article 28 providers of recent changes to fee-for-service immunization policy and to clarify existing immunization policy and billing guidelines.

NOTE: The following policy guidance applies to Article 28 providers. Additional policy and billing guidance that applies specifically to Local County Health Department (LCHD) clinics and School Based Health Centers (SBHCs) is addressed in separate sections of this article.

Changes to Immunization Policy The following changes have been made to Medicaid's immunization policy.

The following section contains clarification of immunization policy and detailed billing guidelines -

  • Effective October 1, 2011, (retroactive to 12/1/08), the "SL" modifier, used to denote administration of vaccines provided through the Vaccine for Children (VFC) program, was added to the APG system.
  • Effective October 1, 2011, (retroactive to 10/1/10), a new modifier, "FB," was added to APGs. This modifier allows providers to bill for the administration of "free" vaccines that have been administered to enrollees age 19 and older.
  • Effective October 1, 2011, the list of vaccines that can be administered to a Medicaid enrollee with a non-patient specific standing order was expanded to mirror the NY State Education Department's (SED's) list of vaccines. The current list is provided at the end of this article. Providers should follow SED's Protocol Requirements, when administering vaccines with non-patient specific standing orders. SED’s Protocol Requirements can be accessed at the following link:

Clarification of Immunization Policy and Billing Guidelines Vaccines Provided to Medicaid Enrollees under Age 19 (Excluding Influenza and Pneumococcal vaccines)

  • Vaccines administered to Medicaid enrollees under the age of 19 years old are supplied through the Vaccine for Children (VFC) program.
  • Vaccines provided through the VFC program are free. An administration fee of $17.85 is paid per vaccine dose administered.
  • Effective October 1, 2011, (retroactive to 12/1/08), VFC vaccines are to be billed as APG line items.
  • Providers should bill using the CPT code that represents the vaccine administered and append the vaccine code with the "SL" modifier (indicating State Supplied Vaccine). Only the VFC administration fee will be paid ($17.85).
  • Providers should not bill an additional CPT code for vaccine administration. The "SL" modifier indicates administration of a State supplied vaccine through the VFC program, and thereby generates payment of the enhanced administration fee of $17.85.

Vaccines Provided to Medicaid Enrollees Age 19 and Older (Excluding Influenza and Pneumococcal vaccines) -

  • Immunizations, provided to Medicaid enrollees age 19 and older, are to be billed as APG line items.
  • The CPT code for the vaccine administered should be reported on the claim.
  • A separate payment for vaccine administration will not be made. Payment for vaccine administration is folded into the APG payment for the vaccine material.

Vaccines (for individuals age 19 and older) Supplied at NO COST to the Provider

  • Providers administering free vaccine to enrollees age 19 and older should report the CPT code for the vaccine administered appended with the "FB" modifier.
  • An administration fee of $13.23 will be paid.
  • Providers should not bill an additional CPT code for vaccine administration. The "FB" modifier replaces the administration code and generates payment of the enhanced administration fee of $13.23.

Influenza and Pneumococcal Vaccines

  • Influenza and pneumococcal vaccines can be billed as APG line items or as ordered ambulatory services. When provided as ordered ambulatory services, influenza and pneumococcal vaccines can be billed using the ePACES template for billing.
  • When administered to individuals under age 19, the CPT code for the immunizing agent that was provided should be appended with the “SL” modifier (an administration code should not be billed). An enhanced administration fee of $17.85 will be paid.
  • When administered to individuals age 19 and older, the CPT code for the immunizing agent that was provided and the associated administration code, G0008 (flu) and G0009 (pneumococcal), should be specified. An enhanced administration fee of $13.23 will be paid.
  • Immunizations provided at School Based Health Centers (SBHCs) are carved out of Managed Care and are billable to fee-for-service Medicaid. The following non-APG rate codes are carved out of the managed care benefit package, and allow Medicaid to reimburse SBHCs for the administration of these vaccines to Medicaid Managed Care beneficiaries. Reimbursement ($17.85) is available for vaccine administration only, since the vaccine is distributed free-of-charge through the Vaccine for Children's (VFC) program.
  • Seasonal flu - Rate code 1381
  • Pneumococcal - Rate code 1383

Guidelines for School Based Health Centers Billing for Immunizations other than Flu and Pneumococcal

As previously noted, immunizations provided at School Based Health Centers (SBHCs) are carved out of Medicaid Managed Care and are billable to fee-for-service Medicaid. SBHCs should bill for all immunizations, other than the seasonal flu and pneumococcal immunizations, using their SBHC rate codes.

  • Hospital Outpatient Department SBHC Rate codes - Visit 1444; Episode 1450
  • Diagnostic & Treatment Center SBHC Rate codes - Visit 1447; Episode 1453

The CPT code for the immunization should be appended with the "SL" modifier and billed to Medicaid under APGs.

Billing Guidelines for Local County Health Department Clinics

  • Local county health department clinics, unlike other Article 28 providers, do not provide primary care services to registered clinic patients.
  • The following billing policy applies to LCHD clinics:
  • If a Medicaid enrollee, age 19 or older, is referred to the LCHD clinic for an immunization(s) by his/her primary care physician/ practitioner, the LCHD clinic should bill for the immunization as an Ordered Ambulatory service (using the fee schedule) at the actual acquisition cost to the provider. A $2.00 fee for vaccine administration should be added to the cost of the vaccine.
  • If a Medicaid enrollee, age 19 or older, presents to the LCHD clinic for an immunization as a self-referral, the LCHD clinic should bill for the immunization as an APG line item. Instructions for APG billing, as previously outlined in this article, are to be applied.
  • Vaccines provided free of charge to adults and children should be billed under APGs using the appropriate modifier ("FB" or "SL").

Non-Patient Specific Standing Orders

When provided within their scope of practice, licensed health care practitioners may administer vaccines under non-patient specific or standing orders. The list of vaccines that can currently be administered under non-patient specific orders and State Education Department’s (SED’s) Protocol Requirements can be accessed at the following link:

The current list for adults and children is included in Table 1. Updates to the list will be posted on the SED website.

Table 1: Immunizing Agents that May be Administered Under Standing Orders

Immunizing Agents for Adults Immunizing Agents for Children
Acellular Pertussis Acellular Pertussis
Diphtheria Diphtheria Hepatitis A Haemophilus Influenza Type B (HIB)
Hepatitis B Hepatitis A
Herpes Zoster vaccine Hepatitis B
Human Papilloma Virus (HPV) Human Papilloma Virus (HPV)
Inactivated Polio Inactivated Polio
Influenza Influenza
Measles Measles
Meningococcus Meningococcus
Mumps Mumps
Pneumococcus Pneumococcal Conjugate
Rubella Rotavirus
Smallpox Vaccine Rubella
Tetanus Tetanus
Varicella Varicella

Transportation to be Carved-Out for Managed Care Enrollees in New York City

Under the Medicaid Redesign Team (MRT) Initiative #29, the Department is phasing in a Medicaid fee-for-service non-emergency medical transportation (NEMT) management program under which transportation services are carved-out of the Medicaid managed care benefit package. The first NEMT program for managed care enrollees was implemented in the Hudson Valley Region in January 2012, with additional counties in the region moving to the NEMT manager in March and September of 2012 (see chart below).

Beginning January 1, 2013, the following transportation services will be carved-out of the managed care benefit package for managed care enrollees in all New York City boroughs:

1) emergency and non-emergency transportation services for all Medicaid managed care enrollees in the region: and

2) non-emergency transportation only for Family Health Plus (FHPlus) enrollees aged 19 through 20 in the region.

Medical providers in NYC are advised to contact LogistiCare, the NYC NEMT manager, at the numbers below to arrange for transportation of managed care enrollees:

Contact Information for Providers

NYC Facility Services Dept. (For facility transportation arrangements) 877-564-5925
Brooklyn facility fax 877-585-8758
Queens facility fax 877-585-8759
Manhattan facility fax 877-585-8760
Bronx facility fax 877-585-8779
Staten Island facility fax 877-585-8780
Hospital Discharge 877-564-5926

Managed care enrollees may use the numbers below to make their own transportation arrangements through LogistiCare or to register a complaint:

Contact Information for Enrollees

NYC Reservations (For enrollee reservations) 877-564-5922
NYC Ride Assist (For transportation complaints) 877-564-5923

The regional carve-out schedule for transportation of managed care enrollees in the Hudson Valley Region is provided below:

  • January 1, 2012 - Albany, Columbia, Fulton, Greene, Montgomery, Orange, Putnam, Rockland, Sullivan, Ulster, Warren, Washington, Westchester.
  • March 1, 2012 - Broome, Cayuga, Dutchess, Oneida, Onondaga, Rensselaer, Schenectady, Schoharie.
  • September 1, 2012 - Delaware, Essex, Saratoga.

Members and medical providers in the Hudson Valley Region should be advised to contact Medical Answering Services, LLC (MAS), at the county specific numbers provided:

Albany County 855-360-3549
Broome County 855-852-3294
Cayuga County 866-320-5655
Columbia County 855-360-3546
Delaware County 866-753-4434
Dutchess County 866-244-8995
Essex County 866-753-4442
Fulton County 855-360-3550
Greene County 855-360-3545
Montgomery County 855-360-3548
Oneida County 855-852-3288
Onondaga County 855-852-3287
Orange County 855-360-3543
Putnam County 855-360-3547
Rensselaer County 855-852-3293
Rockland County 855-360-3542
Saratoga County 855-852-3292
Schenectady County 855-852-3291
Schoharie County 855-852-3290
Sullivan County 866-573-2148
Ulster County 866-287-0983
Warren County 855-360-3541
Washington County 855-360-3544
Westchester County 866-883-7865

Questions concerning the Medicaid fee-for-service transportation benefit should be directed via e-mail


Practitioner Reimbursement for Palivizumab (Synagis®)

Medicaid reimburses for palivizumab when billed by Medicaid enrolled physicians and nurse practitioners and should be billed as follows:

  • Use code 90378 - Respiratory syncytial virus monoclonal antibody, recombinant.
  • Submit the valid 11 digit NDC, quantity, and units on the claim.
  • Insert the acquisition cost plus a two-dollar ($2.00) administration fee in the "amount charged" field.
  • If administering palivizumab outside the guidelines, a paper claim with medical justification must be submitted.

For more information on practitioner billing, please review the Physician Provider Manual, Procedure Code and Fee Schedule, Procedure Codes Medicine and Drugs (Section 2), Version 2012-1 (4/1/2012), available at:

Please call the eMedNY Call Center at (800) 343-9000 with billing questions.

Clinic Reimbursement for Palivizumab (Synagis®)

Palivizumab is reimbursable to hospital-based and free-standing clinics and is reimbursed under Ambulatory Patient Groups (APGs).

When billing the cost and administration of palivizumab for registered clinic patients under APGs:

  • For the immune globulin, use CPT procedure code 90378, respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50mg, each. This will group to APG 416, Level III Immunization.
  • Submit the valid 11 digit NDC, quantity, and units on the claim.
  • For the administration, use CPT 90460 Immunization administration through 18 years via any route of administration, with counseling by a physician or other qualified health care professional: first or only component of each vaccine or toxoid administration. This will group to APG 490 and will not pay at the line level.

Please call the eMedNY Call Center at (800) 343-9000 with billing questions.

Palivizumab (Synagis®)Clinical Drug Review Program (CDRP) Process

As respiratory syncytial virus (RSV) season approaches, Medicaid pharmacy providers should be aware that prescriptions obtained for palivizumab are subject to Clinical Drug Review Program (CDRP) prior authorization requirements. Prior authorization requirements are intended to ensure that utilization of prescriptions written for RSV occur within the RSV season and for children less than two years of age at the onset of the RSV season.

  • Prescriptions for children less than two years of age at the onset of the RSV season may be dispensed and billed (on-line) between October 16 and March 31 without prior authorization.
  • Prescriptions obtained between April 1 and October 15 requires prior authorization.
  • Prescriptions obtained for children two years of age and over at the onset of RSV season require prior authorization.*

Prior authorizations must be initiated by the prescriber by calling (877) 309-9493 and following the appropriate prompts. Prescription refills are limited to four per patient.

Pharmacy providers must submit POS claims at the time of dispensing to ensure appropriate payment.

The CDRP Prescriber worksheet and Instructions provide step-by-step assistance in completing the prior authorization process.

For clinical information on bronchiolitis, please visit:

*The Department of Health determines RSV season based on information from the CDC.

For Medicaid Pharmacy prior authorization program questions, please call (877) 309-9493. For billing questions, please call the eMedNY Call Center at (800) 343-9000.

Cost of Dispensing Survey Soon Available

In accordance with legislation passed in April 2011, the Department of Health is undertaking a comprehensive survey of Medicaid enrolled pharmacies to identify average acquisition costs (AAC) and associated costs of dispensing (COD). The overall goal of this Medicaid Redesign Team (MRT) initiative is to create a pharmacy reimbursement benchmark that is valid, transparent, timely and sustainable.

On September 27, 2012, the initial COD survey will be released. All Medicaid fee-for-service enrolled providers are required to participate in this survey, except those providers that submitted data in the COD pilot survey. Data collected will allow the Department to establish a pharmacy dispensing fee that accurately reflects the cost to dispense a Medicaid prescription.

The COD survey is an online survey located on the HCS website under the Medicaid Pharmacy Cost of Dispensing Survey application. COD surveys must be submitted by October 18, 2012. We encourage providers to begin preparing the documents as soon as possible so they are able to submit by the deadline. Data will be collected through the Health Commerce System (HCS) to ensure confidentiality and security of the information.

On September 20, 2012, the Department mailed information and instruction booklets to all independent pharmacies. Instruction booklets specific to the chain pharmacies were sent to store headquarters via e-mail.

Enrolled pharmacies that are not currently affiliated with an active HCS account must do so immediately. To obtain an account or to verify whether your pharmacy is affiliated with an existing account, please send an e-mail to following the instructions on page six in the instruction manual.

If you have questions, please contact the Department via e-mail at:

Additional information is available at:

Transmission of the Official Prescription Serialized Number is now required for Medicaid Managed Care and Family Health Plus (FHPlus) Plans

Note: This article was inadvertently omitted from the August 2012 Update: Effective September 20, 2012, Medicaid Managed Care and Family Health Plus (FHPlus) plans are required to capture the serialized number from the Official Prescription in accordance with guidance originally set forth in the October 2006 Medicaid Update. Medicaid Managed Care and Family Health Plus have communicated the specific requirements to their pharmacy network.

NYS Medicaid Pharmacy Prior Authorization Programs Update

Enhancements to the Preferred Drug List (PDL) will now allow providers to access more comprehensive information on Medicaid fee-for-service prior authorization requirements. In addition to providing PA requirements for the Preferred Drug Program (PDP), Clinical Drug Review Program (CDRP), and the Drug Utilization Review Program (DURP), the PDL now also includes information on the Brand Less Than Generic (BLTG) Program. To access the complete PDL, please visit:

If prior authorization (PA) is required, please contact the clinical call center at (877)309-9493 for assistance. The clinical call center is available 24 hours per day, 7 days per week with pharmacy technicians and pharmacists who will work with you, or your agent, with PA assistance. For additional information on the Medicaid Pharmacy Prior Authorization Programs, please visit the following websites: or or

e-Prescriber Payments to be Issued By eMedNY

To encourage the use of e-prescribing, New York State law authorizes the payment of an incentive to eligible medical practitioners for each approved ambulatory Medicaid e-prescription plus a maximum of five refills per prescription. Incentive payments have been sent to providers for e-scripts through December 2011.

In Cycle 1830 (check dated 9/17/12, release/mail date 10/3/12), the e-prescriber incentive payments for first and second quarter 2012 will be issued by eMedNY, and appear as a financial transaction (lump-sum payment) on the provider’s Medicaid remittance statement. On the remittance (paper or electronic) the financial control number (FCN) will appear as LSE to indicate an e-prescribing payment.

Questions may be directed to the eMedNY Call Center at (800) 343-9000.

The New York State Medicaid Prescriber Education Program Drug Information Response Center

Addressing Calcium Channel Blocker-Induced Peripheral Edema

The New York State Medicaid Prescriber Education Program (NYSMPEP) is a collaboration between the New York State Department of Health (NYSDOH) and the State University of New York (SUNY), as approved by state legislation. This program was designed to provide prescribers with an evidence-based, non-commercial source of the latest objective information about pharmaceuticals. In conjunction, the Drug Information Response Center (DIRC) was developed to fulfill the mission of assisting clinicians in the delivery of health care to their Medicaid patients by providing timely, evidence-based information on pharmacotherapy to prescribers and serving as a resource for NYSMPEP academic educators in their outreach to prescribers. The following review was prepared by the DIRC in response to a request for information on calcium channel blocker (CCB)-induced peripheral edema.

Peripheral edema is a well-documented side effect of CCBs.1-3 CCBs inhibit the influx of calcium across cell membranes, blocking L-type (high-voltage-gated) calcium channels, specifically.1 Per Dipiro, the flow of calcium from extracellular fluid to the intracellular space is necessary for contraction of cardiac and smooth muscle cells. Inhibition of this process leads to coronary and peripheral vasodilation. Edema, also known as swelling caused by an increase in interstitial volume,4 may occur with use of CCBs due to arterial vasodilation, which results in redistribution of fluid from the vascular space into the interstitium. Per Makani et al,5 peripheral edema is one of the most common dose-dependent side effects of CCBs but may vary among the individual agents.

CCBs may be categorized into 2 classes: dihydropyridines and non-dihydropyridines. Although they are similar in antihypertensive effects, they differ in other pharmacodynamic effects. Generally, per Dipiro, edema and other side effects associated with vasodilation (e.g., dizziness, flushing, and headache) occur more frequently with dihydropyridines (e.g., amlodipine, felodipine, nifedipine).1 Comparatively, non-dihydropyridines (e.g., diltiazem and verapamil) are less potent vasodilators. Per Facts and Comparisons, mild to moderate peripheral edema occurs in 10% to 30% of patients receiving nifedipine.3 This edema typically manifests in the lower extremities and is responsive to diuretic therapy. Peripheral edema may also occur with felodipine, within 2 to 3 weeks of initiation; the incidence has been shown to be age- and dose-dependent with a lower incidence (~10%) in patients under 50 years of age on a daily dose of 5 mg and higher incidence (~30%) in patients over 60 years of age receiving a daily dose of 20 mg.

Makani et al sought to evaluate the incidence of edema secondary to CCB use and performed a meta-analysis of randomized controlled trials involving CCBs.5 Trials involving >100 patients and ≥4 weeks in duration were included. A total of 166 trials involving 99,469 patients were analyzed. The most commonly studied CCB was amlodipine (52 trials), followed by nifedipine (21 trials), diltiazem (12 trials), felodipine (9 trials), isradipine (8 trials), and lacidipine (7 trials). Other CCBs studied were lercandipine, verapamil, nitrendipine, nisoldipine, barnidipine, manidipine, nicardipine, and pranidipine. (Of note, lacidipine, lercandipine, nitrendipine, barnidipine, manidipine, and pranidipine are not available in the U.S.).

The investigators observed a higher rate of peripheral edema in the CCB groups vs. comparators (10.7%%vs. 3.2%, p<0.0001) and a higher withdrawal rate due to peripheral edema in the CCB groups (2.1% vs. 0.5%, p<0.0001). The incidence and withdrawal rates were found to increase with duration of therapy at 24% and 5%, respectively, after 6 months. A dose-related effect was also observed; the incidence of edema in patients taking higher doses (more than half the usual maximum dose) was 16.1% compared to 5.7% in those taking lower doses (p<0.0001). Comparing non-dihydropyridines to dihydropyridines, Makani et al observed a higher incidence in patients on dihydropyridines (12.3% vs. 3.1%, p<0.0001). In addition, comparing newer lipophilic (e.g., lacidipine, lercandipine, and manidipine) to traditional dihydropyridine CCBs, the investigators observed a 57% lower incidence of edema with the lipophilic agents (relative risk [RR]: 0.43; 95% confidence interval [CI]: 0.34 to 0.53).

Of note, peripheral edema associated with CCB use does not necessarily reflect underlying congestive heart failure. In fact, several sources caution that this side effect should be clearly distinguished from peripheral edema secondary to heart failure (e.g., rule out signs of left ventricular dysfunction, and consider a complete cardiovascular examination).1,2,5 Makani et al address this in their meta-analysis.5 The investigators state that peripheral edema is considered to be a common and "annoying" adverse effect of CCBs and also note that studies involving patients with coronary artery disease or heart failure were excluded from their analysis.

In summary, there appears to be a consensus that CCBs may cause edema through vasodilation. It should be noted that differences in the incidence have been demonstrated among the CCBs. Differences in the incidence of edema may also be related to dose and duration of CCB therapy, as well as patient-specific factors (e.g., age).

To contact a NYSMPEP academic educator in your area, please visit:


  1. Saseen JJ, Maclaughlin EJ. Hypertension. In: Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York, NY: McGraw-Hill; 2011:124.
  2. Saseen JJ. Essential hypertension. In: Koda-Kimble MA, Young LY, Alldredge BK, et al, eds. Applied Therapeutics: The Clinical Use of Drugs. 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009:13-33.
  3. Facts and Comparisons® [Internet database]. St. Louis, MO: Wolters Kluwer Health. Updated periodically.
  4. Micromedex® Healthcare Series [Internet database]. Greenwood Village, CO: Thomson Healthcare. Updated periodically.
  5. Makani H, Bangalore S, Romero J, et al. Peripheral edema associated with calcium channel blockers: incidence and withdrawal rate - a meta-analysis of randomized trials. J Hypertens. 2011:29(7):1270-1280.

Exclusive Pharmacy Network in Managed Care

Per the SFY 2012-13 enacted budget, the Department of Health developed criteria to be used to determine which drugs may be included in the Medicaid Managed Care Organizations (MCO) exclusive pharmacy networks. Drugs that were already included in any of the Medicaid Managed Care plans’ exclusive/specialty pharmacy networks were evaluated against the criteria. The criteria and two drug lists (one that included drugs that meet the criteria, and one that included drugs that did not meet the criteria) were distributed for comment at the end of July 2012.

The Department has carefully reviewed all stakeholder comments, resulting in the development of a comment and response document and two revised drug lists. Effective October 8, 2012, the managed care plans will implement the appropriate changes to their exclusive/specialty pharmacy networks to maintain compliance with the list of drugs that meet the established criteria.

Additional information regarding the Exclusive Pharmacy Network in Managed Care is available online at:

Change in Coverage of Benzodiazepines and Barbiturates for Dual Eligible Population

Medicare Part D prescription drug plans and MA-PD plans are not currently required to include barbiturates or benzodiazepines in their formularies. For prescriptions dispensed on or after January 1, 2013, these Medicare drug plans will be required to cover benzodiazepines for any condition and barbiturates used for the treatment of epilepsy, cancer, or a chronic mental health disorder. Only drugs that are excluded by law from being covered by the Medicare Part D plans are covered by NYS Medicaid for dual eligibles (Medicare/Medicaid). As a result, effective January 1, 2013, NYS Medicaid will no longer provide dual eligibles with coverage of benzodiazepines for any condition and barbiturates when prescribed for Medicare Part D covered indications.

NYS Medicaid will continue to provide coverage of barbiturates for dual eligibles when prescribed for indications not covered by Medicare Part D. In addition, NYS Medicaid continues to cover benzodiazepines and barbiturates for NYS Medicaid beneficiaries who are not Medicare eligible. Barbiturates prescribed for dual-eligibles for non Medicare Part D covered indications will be subject to prior authorization and will require documentation of Medicare Part D denial.

Reporting of the National Drug Code (NDC) is now required for all Physician Administered Drugs for Medicaid Managed Care and Family Health Plus (FHPlus) Plans

Note: This article was inadvertently omitted from the August 2012 Update Table of Contacts

Effective September 20, 2012, Medicaid Managed Care and Family Health Plus (FHPlus) plans require network providers to report the NDC on the claim when billing for physician administered drugs in accordance with guidance originally set forth in the June 2008 Medicaid Update. Medicaid Managed Care and Family Health Plus plans are communicating the specific requirement to their provider network

All Providers

Medicaid to Discontinue Use of the Omni 3750 Point of Service (POS) Device

Effective in early 2013 eMedNY will no longer support the Omni 3750 POS Device. The exact date of the discontinuance will be provided in future Medicaid Update articles. Providers who currently use the Omni 3750 POS Device to verify Medicaid eligibility or request Dispensing Validation System (DVS) prior approval should make plans immediately to switch to one of the alternate methods listed. For providers participating in the Office of Medicaid Inspector General’s (OMIG) Cardswipe Program, please continue to use the Omni 3750 terminal for your Medicaid transactions until further notice.

Real Time Options


  • Internet access, free, easy-to-useInternet access, free, easy-to-use; supports a variety of transactions
  • MEVS eligibility; DVS; Claim status for any of your claims; Institutional, Professional, and Dental claims; prior authorizations.

eMedNY Simple Object Access Protocol (SOAP)- Real Time

  • Internet accessible; provides the capability of integrating with your current system uses an already existing FTP or ePACES user ID; supports MEVS eligibility (does not support DVS.)

Batch Options(do not support DVS)

eMedNY eXchange

  • Internet accessible; easy-to-use - works like an e-mail mailbox; no special scripting or software necessary to upload or download files; files retained for 28 days after submission; ePACES user ID is used to access your eMedNY eXchange mailbox; able to receive 835/820 Electronic Remits, PDF Remits, PA Rosters.

FTP (Dial-up)

  • For those without high speed Internet access; login and file transmission is fully scriptable able to receive 835/820 Electronic Remits.

eMedNY Simple Object Access Protocol (SOAP) - Batch

  • Internet accessible; Provides the capability of integrating with your current system; eMedNY SOAP is an XML based protocol which enables applications to exchange information over Hyper Text Transfer Protocol (HTTP); uses an already existing FTP or ePACES user ID.

Several large clearinghouses and service bureaus maintain direct real-time connections to eMedNY. Providers should check with their clearinghouse/service bureau vendor to see if they can support the real time transactions that you utilize on the Omni 3750. At some point eMedNY may no longer be able to support POS devices. Providers currently using one of these devices are encouraged to consider one of the listed alternate methods. If the alternate methods listed are not feasible providers may wish to purchase the Verifone Vx570 POS Device. Questions and requests for technical assistance transitioning to an alternate access method may be forwarded via e-mail to or providers may contact the eMedNY Call Center at (800) 343-9000.

New Training Schedule and Registration

  • Do you have billing questions?
  • Are you new to Medicaid billing?
  • Would you like to learn more about ePACES?

If you answered YES to any of these questions, consider registering for a Medicaid training session. eMedNY offers various types of educational opportunities to providers and their staff. Training sessions are available at no cost to providers and include information for claim submission, Medicaid Eligibility Verification, and the eMedNY website.

Web Training Now Available

You may also register for a webinar. Training will be conducted online and you will be able to join the meeting from your computer and telephone. After registration is completed, just log in at the announced time. No travel involved. No travel involved.

Many of the sessions planned for the upcoming months offer detailed instruction about Medicaid's free web-based program ePACES, the electronic Provider Assisted Claim Entry System that allows enrolled providers to submit the following type of transactions:

  • Claims
  • Eligibility Verifications
  • Claim Status Requests
  • Prior Approval/DVS Requests

Physician, Nurse Practitioner, DME and Private Duty Nursing claims may even be submitted in "REAL-TIME" via ePACES. Real-time means that the claim is processed within seconds and professional providers can get the status of a real-time claim, including the paid amount without waiting for the remittance advice.

Fast and easy registration, locations, and dates are available on the eMedNY Website at:

eMedNY representatives look forward to having you join them at upcoming meetings!

If you are unable to access the Internet to register or have questions about registration, please contact the eMedNY Call Center at (800) 343-9000.

Provider Directory

  • Office of the Medicaid Inspector General: For general inquiries or provider self-disclosures, please call (518) 473-3782. For suspected fraud complaints/allegations, call 1-877-87FRAUD (1-877-873-7283), or visit
  • Provider Manuals/Companion Guides, Enrollment Information/Forms/Training Schedules: Please visit the eMedNY website at:
  • Providers wishing to hear the current week's check/EFT amounts: Please call (866) 307-5549 (available Thursday PM for one week for the current week's amount)
  • Do you have questions about billing and performing MEVS transactions? Please call the eMedNY Call Center at (800) 343-9000.
  • Provider Training: To sign up for a provider seminar in your area, please enroll online at: For individual training requests, call (800) 343-9000 or e-mail:
  • Enrollee Eligibility: Call the Touchtone Telephone Verification System at (800) 997-1111.
  • Need to change your address? Does your enrollment file need to be updated because you've experienced a change in ownership? Do you want to enroll another NPI? Did you receive a letter advising you to revalidate your enrollment? Visit and choose the link appropriate for you (e.g., Physician, Nursing Home, Dental Group, etc.)
  • Do you have comments and/or suggestions regarding this publication?
  • Please contact Kelli Kudlack at: