New York State Medicaid Update - May 2023 NYRx Pharmacy Benefit Transition: Part Four Special Edition Volume 39 - Number 9










Effective April 1, 2023, New York State (NYS) Medicaid members enrolled in mainstream Medicaid Managed Care (MMC) Plans, Health and Recovery Plans (HARPs), and Human Immunodeficiency Virus-Special Needs Plans (HIV-SNPs) receive their pharmacy benefits through NYRx, the NYS Medicaid Pharmacy program [formerly known as NYS Medicaid fee-for-service (FFS)], 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 (EP), or Child Health Plus (CHPlus)].

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 following Medicaid Update issues:

Member Identification Number

Pharmacies should bill NYRx using the Client Identification Number (CIN), which can be found on both the NYS Benefit card and the MMC Plan card of the NYS Medicaid member.

  • The Client Identification Number or CIN is a unique number assigned to each NYS Medicaid member. This number is used by the pharmacy to submit pharmacy claims to NYRx. All NYS Medicaid members are assigned a CIN even if they are enrolled in an MMC Plan. The CIN is located on all NYS Medicaid member cards including MMC Plan cards. On some MMC Plan cards it is referred to as CIN; however, other MMC Plan cards may identify it as Program ID, Member ID, or ID#. On some cards, it may be embedded into a longer number. The CIN is always represented in the following format: "XX00000X". Please note: The sequence number is not required for submitting claims.
Member Identification Number












  • For assistance locating the CIN on an MMC Plan card, pharmacies should visit the New York State Medicaid Managed Care (MMC) Pharmacy Benefit Information Center website. On the New York State Medicaid Managed Care (MMC) Pharmacy Benefit Information Center Information Center homepage, providers can select a plan to display an image of the MMC Plan card that indicates where the CIN is located.
    • Bank Identification Number (BIN) and Processor Control Number (PCN): For submitting NYRx claims to NYS Medicaid via National Council for Prescription Drug Program (NCPDP) D.0, the BIN number is required in field 101-A1 and is "004740". The PCN (Processor Control Number) is required to be submitted in field 104-A4. The PCN has two formats, which are comprised of 10 characters:
      • First format for 3-digit Electronic Transaction Identification Number (ETIN):
        "Y"- (Yes, read Certification Statement)- (1)
        Pharmacist's Initials-(2)
        Provider PIN Number-(4)
        3-digit ETIN-(Electronic Transaction Identification Number)- (3)
      • Second format for 4-digit ETIN:
        Pharmacist's Initials-(2)
        Provider PIN Number-(4)
        4-digit ETIN- (Electronic Transaction Identification Number)- (4)

MMC Plan ID Card Format:

Plan Name Member/Enrollee Plan Identification (ID) Number: "Member Plan ID# is Client Identification Number (CIN)", "Embedded in Plan ID#", or "CIN Shown Separately on Plan Card"
Affinity by Molina Healthcare CIN Shown Separately on Plan Card
Amida Care Member Plan ID# is CIN
CDPHP CIN Embedded in Member's Plan ID#
Emblem Health CIN Embedded in Member's Plan ID#
Empire BCBS HealthPlus Member Plan ID# is CIN
Excellus CIN Shown Separately on Plan Card
Fidelis CIN Shown Separately on Plan Card
Healthfirst Member Plan ID# is CIN
Highmark BCBS of Western NY CIN Shown Separately on Plan Card
Independent Health CIN Embedded in Member's Plan ID#
MetroPlus Member Plan ID# is CIN
Molina Healthcare Member Plan ID# is CIN
MVP Healthcare CIN Shown Separately on Plan Card
United Healthcare CIN Shown Separately on Plan Card
Univera Healthcare CIN Shown Separately on Plan Card
VNS Health CIN Shown Separately on Plan Card

Pharmacy Programs:

  • Preferred Drug Program (PDP)
    The PDP program, promotes the use of less expensive, equally effective prescription drugs when medically appropriate. All drugs currently covered by NYS 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 NYS Medicaid. Reminder: Preferred products, used in accordance with Food and Drug Administration (FDA) labeling, may not require prior authorization (PA). To switch to a Preferred product, prescribers should refer to the NYRx, the Medicaid Pharmacy Program Preferred Drug List.
  • Brand Less Than Generic (BLTG) Program
    The BLTG 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 to the NYS Medicaid, than the generic equivalent.
  • Preferred Diabetic Supply Program (PDSP)
    NYS Medicaid participates in a PDSP, to provide NYS Medicaid members access to quality glucose meters and test strips, while at the same time reducing overall program costs.

Edit Resolution

Pharmacies should review the NYRx, The Medicaid Pharmacy Program: Top Edit Resource document, which contains important phone numbers, general resources, and a chart of the most common NYRx edits including the edit description, the NCPDP reject response and information on how to resolve the claim denial. For additional information, pharmacies can refer to the following links:

Prescribers and Enrollment

Providers who prescribe drugs and supplies for NYS Medicaid members and/or MMC enrollees must be enrolled in NYS Medicaid as either an "Individual Billing" provider or as an "Ordering, Prescribing, Referring, or Attending" (OPRA) provider for NYS Medicaid to cover the products. NYRx will pay for covered products and services for NYS Medicaid members when their prescriber is enrolled in NYRx. There are two paths of enrollment, as a biller or OPRA provider:

Physicians, Nurse Practitioners (NPs), Physician Assistants (PAs), Podiatrists, Dentists, Optometrists, Audiologists, and Certified Nurse Midwives Providers who wish to:

Unlicensed interns, residents, and foreign physicians in training programs are eligible to prescribe for NYS Medicaid members without enrollment as a NYS Medicaid provider. In accordance with NYS Education Law, unlicensed interns, residents, and foreign physicians participating in training programs, are authorized to prescribe. NYS Medicaid recognizes the authority under which these unlicensed providers may prescribe; however, per federal requirements, these physicians are not eligible for enrollment into the NYS Medicaid program without a license.

Pharmacy Billing – Exceptions for Non-Enrolled Prescribers in NYS Medicaid

The NYS Medicaid program requires enrollment of all licensed prescribers who serve NYS Medicaid members and MMC enrollees, 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 NYS Medicaid members for a single instance of emergency care within 180 days.
    1. These prescribers need to be either enrolled in Medicare with an "approved" status or enrolled in their own state's Medicaid program.

Pharmacies will receive a reject code/Place of Service (POS) rejection message for prescriptions written by a non-enrolled prescriber. Pharmacies should utilize the override guidance provided below for the above exceptions specific to NYRx, the Medicaid Pharmacy program.

For NYRx, the Medicaid Pharmacy program, pharmacies should utilize the override instructions provided below:

  • Pharmacy claims will initially reject for NCPDP Reject Code "889" - Prescriber Not Enrolled in State Medicaid Program.
  • To override a 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)

Drug Shortages and Out of Stock Medications

When medications are in shortage or out of stock, pharmacies should make reasonable efforts to contact other enrolled pharmacies to see if another pharmacy has a medication in stock and if available, transfer to the prescription to the other pharmacy. The pharmacy may also contact the prescriber to discuss alternative options and obtain a new prescription if needed.

The NYS Department of Health (DOH) continuously monitors drug shortages and will make adjustments as necessary. Pharmacies should review the American Society of Health-System Pharmacists (ASHP) "Current Drug Shortages" web page, to confirm drug shortages and alternative options.

Practitioner Administered Drugs

NYS DOH recognized the need for certain drugs requiring administration by a practitioner to be available through the Medical and Pharmacy Benefit through NYRx. Practitioner administered drugs (PADs) that are listed on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page, may be billed directly to NYRx, under the pharmacy benefit. PADs obtained by a practitioner must be billed as a medical claim to the MMC Plan of the enrollee.

NYS DOH analyzed PADs that were provided as a Pharmacy Benefit through MMC Plans. As a result of this analysis, NYS DOH added certain PADs to the NYRx formulary. To view all PADs additions, practitioners can refer to the NYS DOH "Physician Administered Drug Additions to NYRx Formulary" web page. Please note: PADs dispensed as a Pharmacy Benefit must be delivered by the pharmacy directly to the site of administration.

Additional information regarding pharmacy dispensing of PADs and delivery requirements is available in the NYRx, The NY Medicaid Pharmacy Program - Pharmacy Manual Policy Guidelines, under the following sections: "Pharmacy Dispensing of Drugs That Require Administration by a Practitioner" and "Delivery." These requirements ensure proper storage and handling.

Coordination of Benefits: Medicare and Other Third-Party Coverage

NYS Medicaid providers, including pharmacies, are required to bill applicable third parties, including Medicare, that may be liable for a claim before billing NYS Medicaid. Medicaid is always the payor of last resort and federal regulations require that all other available resources be used before Medicaid considers payment.

Pharmacies must work with the prescriber and primary insurance to obtain coverage for the NYS Medicaid member. Obtaining coverage could involve PA requirements, appeal processes, or changes to medications ordered to align with the primary plan formulary products, etc. Additional information regarding Coordination of Benefits (COB) can be found in the following Medicaid Update articles:

NYS Medicaid members can make updates to their third-party liability (TPL) coverage by being referred to the place of their enrollment, or by contacting the Consumer Helpline at (800) 541-2831.

Questions and Additional Information:

  • All questions regarding this update should be directed to the Medicaid Pharmacy Policy Unit by telephone at (518) 486-3209 or by email at NYRx@health.ny.gov.
  • FFS claim questions, COB billing questions, or any billing issue should be directed to the eMedNY Call Center at (800) 343-9000.

References and Links:

Additional Resources:

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

Kathy Hochul
Governor
State of New York

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

Amir Bassiri
Medicaid Director
Office of Health Insurance Programs