NYRx Pharmacy Benefit Transition Special Edition - Part Three Volume 39 - Number 5

In this issue …

  1. Medicaid Pharmacy Benefit Transition
  2. Pharmacy Providers
  3. Dual Eligible Coverage
  4. Medicare Limited Income NET Program - LINET
  5. Provider Enrollment
  6. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Providers
  7. Information for DMEPOS Providers
  8. Appendix A: Additional Prior Authorization Guidance
  9. Appendix B: Resources
  10. Appendix C: Member Fact Sheet

Information in gray boxes in this issue indicates material abridged but linked from the succinct interactive Portable Document Format (PDF) version.

|top of page|

I. Medicaid Pharmacy Benefit Transition

Effective April 1, 2023, NYS Medicaid members enrolled in mainstream Medicaid Managed Care (MMC) Plans, Health and Recovery Plans (HARPs), and HIV-Special Needs Plans (SNPs) will receive their pharmacy benefits through NYRx, the Medicaid Pharmacy Program formerly known as Medicaid Fee-for-Service, instead of through their MMC Plan. The pharmacy benefit transition to NYRx does not apply to NYS Medicaid members enrolled in Managed Long-Term Care (MLTC) Plans [e.g., MLTC, Programs of All-Inclusive Care for the Elderly (PACE), Medicaid Advantage Plus (MAP), the Essential Plan, or Child Health Plus (CHP)].

Transitioning the pharmacy benefit from MMC to NYRx will provide NYS with full visibility into prescription drug costs, allow centralization of the benefit, leverage negotiation power, and provide a uniform list of covered drugs with standardized utilization management protocols simplifying and streamlining the drug benefit for NYS Medicaid members. NYS Medicaid members have comprehensive drug coverage and equitable access to an extensive network of over 5,000 pharmacy providers. This guidance provides information in addition to what was provided in the October 2022 Medicaid Update Special Edition - Part One, issued Friday, November 4, 2022, and the January 2023 Medicaid Update Special Edition - Part Two, issued Thursday, February 8, 2023.

|top of page|

Pharmacy Providers

Dual Eligible Coverage

For members who are enrolled in a Medicare Part D drug plan or Medicare Advantage Drug Contracting (MAPD) plan, NYRx provides prescription drug coverage only for the drugs listed below. All other prescription medications should be reimbursed through the Part D plan. For the most up to date coverage information for the products below, providers should refer to the NYRx List of Reimbursable Drugs.

Prescription Drugs:

  • Vitamins
    • Folic acid - oral
    • Hydroxocobalamin - injection
    • Vitamin B12 - injection/nasal
    • Vitamin D2 - oral
    • Vitamin K - oral
  • Cough and Cold
    • Benzonatate

Please Note: NYRx does not provide dual eligible members with coverage of compounded prescriptions.

Over-the-Counter Drugs:

  • NYRx covers certain over-the-counter (OTC) drugs for dual eligible members if coverage is not available under Medicare.
  • Only NYRx reimbursable drugs excluded by Medicare law are covered for dual eligible members. Therefore, NYRx does not cover OTC insulin and some OTC products which have legend drug substitutes that are covered by Medicare Part D and MAPD plans.
  • All OTC products covered by NYRx with a prescription or fiscal order can be found using the drug search tool. Please note search results may include OTC products in the excluded categories listed above that are not covered for dual eligible members.


The links below provide more information on drug coverage under Medicare Part B and D:

Medicare Limited Income Newly Eligible Transition Program (LINET)

LINET is a Medicare program that provides immediate prescription drug coverage for Medicare beneficiaries who qualify for Medicaid or Extra Help and have no prescription drug coverage.

Enrollment in LINET is temporary, usually for 1 to 2 months. This provides the beneficiary time to choose a Medicare Part D prescription drug plan that best fits their needs. If the beneficiary does not select a plan within this timeframe, Medicare will enroll the beneficiary into a benchmark plan.

Claims Processing for LINET
Pharmacies will submit the claim to LINET for reimbursement. Information on LINET, member eligibility, claims processing, and resources available for pharmacies may be found here.

NEW Billing Option for Pen Needles, Syringes and Lancets
Select pen needles, syringes, and lancets may either be billed to NYRx by pharmacy providers on a pharmacy claim using the product's 11-digit National Drug Code (NDC) or the Healthcare Common Procedure Coding System (HCPCS) code and will continue to be able to be billed by DMEPOS providers on a medical claim using HCPCS code. Pen needles, syringes, and lancets reimbursable through NYRx are listed on the NYRx List of Reimbursable Drugs found here.

The 11-digit NDC on the package dispensed must match the NDC billing code on the NYRx List of Reimbursable Drugs and the NDC submitted on the claim. In the event an NDC is not found on the list of reimbursable drugs, providers should submit the claim using the HCPCS code found in the NYS Medicaid Program Pharmacy Medical Supply Codes document. Pharmacies and DMEPOS providers many continue to bill for these items using the HCPCS.

The NYS Department of Health (DOH) will continue to evaluate and consider adding select NDCs of medical supplies commonly billed by pharmacies. Updates to this list will be announced at a later date. The complete list may be found here.

Prescriptions and Orders by Non-Enrolled Prescribers

The New York State (NYS) Medicaid program requires enrollment of all licensed prescribers who serve Medicaid and Medicaid Managed Care members, including prescribing practitioners, as identified on pharmacy prescriptions, per the Centers for Medicare and Medicaid Services (CMS) and federal regulations.

There are two exceptions to the provider enrollment requirement:

  1. Unlicensed Interns, Residents and Foreign Physicians in Training Programs
  2. Out-of-State (OOS) Licensed Prescribers that are treating Medicaid Members for a single instance of emergency care within 180 days. These prescribers need to be either enrolled Medicare with an "approved" status or are enrolled in their own state's Medicaid plan.

Pharmacies will receive a reject code/POS rejection message for prescriptions written by a non-enrolled prescriber. Please utilize the override guidance provided below for the above exceptions specific to NYRx, the Medicaid Pharmacy Program.

  • For NYRx, the Medicaid Pharmacy Program, please utilize the override instructions provided:
    • NEW: Pharmacy claims will initially reject for National Council for Prescription Drug Programs (NCPDP) Reject code "889" - Prescriber Not Enrolled in State Medicaid Program.
    • To override above rejection for the unlicensed resident, intern or foreign physician in a training program or OOS prescription situations described above:
      • In Field 439-E4 (Reason for Service Code): enter "PN" (Prescriber Consultation)
      • In Field 441-E6 (Result of Service Code): enter applicable value ("1A" "1B" "1C" "1D" "1E" "1F" "1G" "1H" "1J" "1K" "2A" "2B" "3A" "3B" "3C" "3D" "3E" "3F" "3G" "3H" "3J" "3K" "3M" "3N" "4A")
      • In Field 420-DK (Submission Clarification Code): enter "02" (Other Override)

|top of page|

Provider Enrollment

Providers servicing MMC members must be enrolled in the NYS Medicaid Program by April 1, 2023.

How to Check Provider Enrollment Status
Providers can check their enrollment status by utilizing the tools available on the Department "Medicaid Enrolled Provider Lookup" web page. Search by entering the Medicaid Provider ID or the National Provider Identifier (NPI). Use the table below to determine current provider enrollment status and the corresponding action necessary, as required from the "Medicaid Type" provided in the result.

Provider Type "Medicaid Type" Enrollment Status Action Required
Pharmacy (Category of Service (COS) 0441) FFS Enrolled (Qualified Billing Provider) No action
No result Not enrolled Enroll with Medicaid as billing provider
Durable Medical Equipment (COS 0321, 0442) FFS Enrolled (Qualified Billing Provider) No action
MCO Not Enrolled for NYRx billing (MCO Billing Only) Enroll with Medicaid as billing provider
No result Not Enrolled Enroll with Medicaid as billing provider
Practitioner/ Prescriber (multiple COS) FFS Enrolled (Qualified Billing Provider) No action
MCO Not Enrolled for NYRx billing (MCO Credentialed as a non-billing Provider) Enroll with Medicaid as billing provider or if eligible as a OPRA provider
OPRA Enrolled (Qualified Billing Provider) No action
No result Not Enrolled Enroll with Medicaid as billing provider or if eligible as a OPRA provider

Providers who have submitted enrollment applications may check the status of their application in the Medicaid Pending Provider Listing file, updated weekly on the eMedNY "Medicaid Managed Care Network Provider Enrollment" web page.

|top of page|

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Providers

The updated Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Provider Enrollment Policy can be found within the NYS Medicaid Program Durable Medical Equipment (DME) Manual Policy Guidelines document.

DMEPOS providers that are located outside New York may apply for enrollment if they meet the newly established guidelines. DMEPOS providers located in states bordering New York may enroll if they support New York Medicaid members in the common medical marketing area. Out-of-state DMEPOS manufacturers and mail-order suppliers may also be considered on a case-by-case basis, as outlined in the NYS Medicaid Program DME Manual Policy Guidelines document.

Information about the DME Supplier application process can be found on the eMedNY Provider Enrollment and Maintenance DME web page.

Information for DMEPOS Providers
The following guidance pertains to providers who service Medicaid members with medical supplies. Medical supplies may be provided by a pharmacy or DMEPOS provider. Pharmacies must have Category of Service (COS) "0442*" to provide medical supplies while DMEPOS providers use COS "0321". Supplies may be provided by either provider type. It is recommended that providers be familiar with the specific Policy and Procedure or Medical Supply Code Manual corresponding to their enrolled COS type and reference it for specific information on coding and other provider specific information.

*Pharmacies that choose to bill via the professional or medical claim format need to be enrolled and have a Medicaid COS of "0442", assigned to them.

Coverage of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
The Scope of Benefits document, provides an overview of DMEPOS items that are subject to the benefit transition. Items that are not subject to the benefit transition will remain the responsibility of the MMC Plans and are listed in Appendix A of this document.

  • The items subject to the benefit transition are listed in Sections 4.1, 4.2, and 4.3 of the DMEPOS - Procedure Codes and Coverage Guidelines document and may be dispensed and billed directly to Medicaid through NYRx or by a FFS DMEPOS provider using the professional claim type. Most items do not require additional authorization prior to dispensing and billing and,
  • The items not subject to the benefit transition are listed in Sections 4.4, 4.5, 4.6, and 4.7 of the DMEPOS - Procedure Codes and Coverage Guidelines document, and should continue to be billed to the member's MMC plan.
  • Hearing aid batteries may be dispensed by pharmacies, DMEPOS providers or by hearing aid providers (COS "0322" and "0324"). Audiologists (COS "0325") cannot be reimbursed for batteries and should be referred to an eligible provider.
  • Supplies distributed by medical providers at the time of an office visit will continue to be reimbursed by the MMC plan.
  • There are some DMEPOS items subject to the benefit transition, that require pre-approval. To ensure a smooth transition for MMC members, DMEPOS authorization requirements will be temporarily relaxed (e.g., claims will not deny) during the transition period which starts April 1, 2023. NYS DOH staff will monitor these claims and outreach to providers to assist them in obtaining the appropriate authorizations for future claims. At a future date, providers will be given notice regarding when PA requirements will commence. For reference, PA instructions are provided in the Prior Authorization Guidance for DMEPOS section of this Special Edition Medicaid Update.

Diabetic Supplies
The Scope of Benefits document, provides a summary of diabetic supply items that are subject to the benefit transition. Diabetic diagnostics, continuous glucose monitors (CGM), glucose testing supplies, insulin syringes, disposable insulin pumps (Omnipod), and infusion supplies will be transitioned to the NYRx program. The NYRx program covers all of these items, some of which are part of the Preferred Diabetic Supply Program (PDSP), found here.

The Medicaid program will allow a one-time transition fill from April 1, 2023, through June 30, 2023, for non-preferred diabetic supplies that are not part of the PDSP and will honor prior authorizations already provided by the MMC Plans.

Practitioner Visits and Medical Supplies
Medical supplies dispensed during a physician's office visit will remain the responsibility of the MMC Plans.

To determine if the product or supply is billable to the member's MMC or subject to the benefit transition, practitioners should reference the Scope of Benefits chart. The chart includes a high-level summary of the NYS Medicaid outpatient pharmacy benefit and denotes whether the benefit is subject to the transition and whether the MMC should also continue to make the benefit available when provided by a non-pharmacy provider.

Billing Instructions for DMEPOS
The table below provides billing instructions for DMEPOS items subject to the benefit transition.

Billing Instructions for DMEPOS
Claim Format Instructions
NCPDP and 000301 paper claim form When billing electronically for medical supplies:
  • Items billed to NYRx using the Healthcare Common Procedure Coding System (HCPCS) code from the NYRx, Medical Supply Codes Billable by a Pharmacy document or the DMEPOS Procedure Codes and Coverage should be submitted in the 11-digit National Drug Code (NDC) field with leading zeros. Enter the five-character alpha-numeric code (example 'A4259') in the last five spaces of the NDC field
  • NCPDP Field Names: Product/Service ID- 407-D7 and Product/Service ID Qualifier- 436-E1 (valid values 01=NDC,09= Healthcare Common Procedure Coding System (HCPCS).
  • If DMEPOS providers submit claim using an NDC number, the claim will deny with reject messages indicated below:
  Code Message
NCPDP Response Code/Message "705" NDC/Antibody Drug Conjugate (ADC) Not Covered
NCPDP Reject Code "70" NDC Not Covered
When billing by paper, refer to the NYS eMedNY Billing Guidelines document.
Professional/ Medical Claim Format 837 (Professional 837-P) or Paper 150003 form* When billing by electronic or paper, refer to the NYS 150003 Billing Guidelines - DMEPOS, Orthopedic Footwear, Orthotic and Prosthetic Appliance document.
Point of Service When submitting claims, refer to the ePACES Professional Real Time Claim Reference
Claims (ePACES) - Real-time DMEPOS Claims submissions Guide

PA Guidance for DMEPOS
DMEPOS supply information can be found in the NYS Medicaid Program DMEPOS Procedure Codes and Coverage Guidelines document. Sections 4.1, 4.2, and 4.3 are subject to the NYRx transition. The manual will provide any necessary medical guidance necessary for each item listed. The manual is coded with information on the type of approval needed (if any) and the quantity and frequency for each item.

Most medical supplies may be reimbursed through claims submissions without any additional approvals. Items that are subject to higher utilization, increased risk for fraud waste and abuse, or require additional review for medical necessity require additional authorizations.

There are three methods of requesting authorizations: Dispensing Validation System (DVS) used for automated Prior Authorizations; Prior Approval; or the Interactive Voice Response System (IVR)/Web Portal for enteral formula.

Dispensing Validation System (DVS) - Automated Prior Authorization
Dispensing Validation System (DVS) is a real-time electronic prior authorization obtained prior to provision of services. DVS will provide an authorization if frequency and quantity are within established guidelines. The DVS system can be accessed through ePACES, a web-based application that allows providers to request and receive HIPAA-compliant transactions.

Prior Approval
Prior Approval is the process of determining if the item(s) requested are medically necessary and appropriate for the member's condition. Prior Approval is also required if the fiscal order written by the ordering provider exceeds the quantity or frequency limits found in the DMEPOS manual.

Interactive Voice Response System (IVR)/Web Portal - Automated Enteral Authorizations
The Interactive Voice Response System (IVR)/Web Portal is the automated system utilized by ordering prescribers and dispensing providers (pharmacies or DMEPOS dealers) for enteral formulas. The ordering prescriber enters medical information into the IVR/Web Portal to medically support enteral formula and receives a prior authorization number to be documented on the fiscal order. The dispenser provider activates the authorization for dispensing and reimbursement. More information on the Web Portal can be found on the DMEPOS Provider Manual page at: www.emedny.org. Training sessions for enteral policy and the Web Portal will be held on March 20, 2023. Visit the eMedNY training page to sign up for these sessions.

|top of page|

Appendix A: Additional Prior Authorization Guidance

DMEPOS Authorizations
DMEPOS Authorizations Resources
HCPCS code is preceded by a pound sign (#).
Prior Authorization
Submitted through the Dispensing Validation System (DVS) through ePACES.
HCPCS code is underlined.
For instructions on completing paper PA forms, refer to the NYS Medicaid Program DME PA Guidelines document.
Prior Approval
Submitted on paper, by a Health Insurance Portability and Accountability Act (HIPAA) 278 transaction or electronically using ePACES.
HCPCS Code is preceded by an asterisk (*)
DiRAD Interactive Voice Response System (IVR)/Web Portal Enteral Authorization
  • Prescriber calls and enters medical information and gets an authorization number and records that on the fiscal order
  • Dispensing provider (DME or Pharmacy) calls and completes the authorization process.
  • Prescribers and Dispensers may also use the web portal to request or complete authorizations The NYS Medicaid Program's Enteral Formula PA Prescriber Worksheet and Enteral Formula PA Dispenser Worksheet are available to assist in the authorization process.
  • PA required for all requests that cannot be completed through the IVR or web portal.

|top of page|

Appendix B: Resources

Topic Description Contact Information & Website Links
Claims Processing for Outpatient Pharmacy Benefits Questions regarding billing and pharmacy claims processing, lost or stolen medications and remittances. eMedNY Support: (800) 343- 9000 - "Option 1" eMedNY home page for General Information eMedNY Pharmacy Manual web page: https://www.emedny.org/ProviderManuals/Pharmacy /index.aspx NYS DOH NCPDP D.0 Standard Companion Guide Transaction Information document
NYRx, the New York Medicaid Pharmacy Program PA criteria Questions regarding PA or Inquiries about quantity/age/day's supply and other edits or medication questions. Magellan Clinical Call Center: (877) 309-9493

PA Request Form for Prescriptions

Magellan Health, Inc., NYS Medicaid Pharmacy Program web page

Magellan Health, Inc., NYS Medicaid Pharmacy Program PDL Listserv email notification sign-up web page
Preferred Diabetic Supply Program Questions regarding billing eMedNY Support: (800) 343- 9000
PA Requests Magellan Clinical Call Center: (877) 309-9493
Preferred Diabetic Supply List and information NYRx, The Medicaid Pharmacy Program, Preferred Diabetic Supply Program web page
Durable Medical Equipment, Prosthetics, Orthotics & Supplies (DMEPOS) (DME) Procedures and Supplies Questions regarding DME PA criteria; frequency/quantity/durations limits, etc., and billing information Phone: (800) 342-3005
Email: ohipmedpa@health.ny.gov

eMedNY DME Manual web page
LINET For questions about the LINET program or a person's retroactive coverage, Phone: (800) 783-1307 (TTY: 711)
Monday - Friday, 8 a.m. - 7 p.m., Eastern time.

Benefit Transition
Pharmacy Information for Consumers, Pharmacies, Providers   Benefit Transition web page
Pharmacy Frequently Asked Questions (FAQs) FAQs Transition of the Pharmacy Benefit from MC to NYRx - FAQs document
Pharmacy Scope of Benefits   Scope of benefits chart webpage
Eligibility Verification and ePACES Questions related to ePACES or for assistance with billing and performing MEVS transactions. eMedNY Support: (800) 343-9000 - "Option 2"
Touchtone Telephone Verification System: (800) 997-1111

ePACES Help/Log-in web page

NYS Programs MEVS Instructions for Completing a Telephone Transaction document
Member's Restricted Recipient Program Providers should direct members to their eligibility location Upstate county residents - Contact your Local Department of Social Services (LDSS)

New York City residents - Contact Human Resources Administration (HRA) by phone at: (212) 273-0062
Policy and Program Information
NYRx Preferred Drug List (PDL) The NYRx PDL contains a full listing of drugs/classes subject to the NYS Medicaid NYRx Pharmacy Programs. Magellan Clinical Call Center: (877) 309-9493

Magellan Rx Management - NYS Medicaid Pharmacy Program web page
Medicaid List of Reimbursable Drugs (Formulary) Providers may review the Medicaid Pharmacy List of Reimbursable Drugs for products covered. Email: NYRx@health.ny.gov

eMedNY's Medicaid Pharmacy List of Reimbursable Drugs web page:
Medicaid Pharmacy Program, Policy and Coverage For questions related to the Pharmacy Program, 340B Billing, Drug Pricing, Lost or Stolen Medications, etc. Pharmacy Bureau: (518) 486-3209
Email: NYRx@health.ny.gov

NYS DOH Medicaid Pharmacy Program web page
Provider Enrollment Provider enrollment, revalidation and NPI termination questions. eMedNY Support: (800) 343-9000 - "Option 2"
Email: providerenrollment@health.ny.gov

eMedNY's Provider Enrollment & Maintenance webpage
Provider Manuals (Physician, Pharmacy, DME, etc.) and Billing Guidelines The Provider Manuals tab has billing and policy related guidance. For example: billing guidelines, procedure codes, fee schedules, etc. for each provider type. eMedNY's Provider Manuals web page

eMedNY's General Billing Guidelines web page
Provider Outreach and Training Providers may visit the training website to review eMedNY trainings available. eMedNY's Provider Training web page

Appendix C: Member Fact Sheet

Please use the Member Fact Sheet to provide members with the resources and information they need regarding the benefit transition. A print-friendly version of the Member Fact Sheet is available on the Medicaid Member Dashboard web page.

Member fact sheet changes


1. Medicaid Provider Enrollment Compendium (MPEC)1

|top of page|

The Medicaid Update is a monthly publication of the New York State Department of Health.

Kathy Hochul
State of New York

James McDonald, M.D., M.P.H.
Acting Commissioner
New York State Department of Health

Amir Bassiri
Medicaid Director
Office of Health Insurance Programs