Information for Providers


Program
Description
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.

Select non-prescription/OTC drugs included in the therapeutic categories listed in the following section may be reimbursed by the New York State Medicaid Program

  • Allergy
  • Analgesic
  • Asthma and Sinus
  • Cough and Cold
  • Digestive
  • Insulin
  • Feminine Products
  • Topical Products  
  • Smoking Cessation  
  • Vitamin/Mineral - when prescribed for a deficiency

For detailed information on covered non-prescription/OTC drugs including National Drug Codes (NDC’s) and maximum reimbursable amounts (MRA) refer to the New York State Medicaid Pharmacy List of Reimbursable Drugs.
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.
Medicaid Redesign homepage
Medical Supplies
  • 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.
  • Medical Supplies Billed via NDC
    • Select pen needles, syringes, and lancets may either be billed to NYRx, the Medicaid Pharmacy Program, 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.
    • Medical Supply Codes Available via NDC
  • Medical Supplies billed via HCPCS code
    • Additional supplies may be billed to NYRx, the Medicaid Pharmacy Program, under the appropriate HCPCS code found in the the NYRx, Medical Supply Codes Billable by a Pharmacy document.
    • Reimbursement for Enteral Therapy, Parenteral Therapy, listed Non-prescription Drugs and Medical/Surgical Supplies is limited to the lower of:
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.
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.
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 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 Administered Drug Policies and Billing Guidance This page contains general information for providers participating in the New York State Medicaid fee-for-service (FFS) program on policies and billing guidance for practitioner administered drugs.