NYRx Information for Medicaid Members

What You Need to Know About Getting Your Prescription Drugs through Medicaid

Your pharmacy benefit is the part of your Medicaid health benefit that helps you pay for your prescription drugs and supplies. As of April 1, 2023, Medicaid members get their drugs through NYRx, the Medicaid Pharmacy Program. This applies to consumers enrolled in Managed Care (MC) plans, Health and Recovery Plans (HARPs) and HIV-Special Needs Plans (HIV-SNPs). Managed Long-Term Care plans (e.g., PACE, MAP, MLTC) and the Essential Plan are not included.

In preparation for the Enacted New York State Budget for Fiscal Year (SFY) 2020-2021, Medicaid Redesign Team (MRT) was tasked with creating cost-saving solutions for Medicaid, so the program could remain financially sustainable while continuing to provide necessary health care services for the more than 6 million New Yorkers who rely on them.

One of these MRT II initiatives was the transition of the Medicaid Pharmacy Benefit from Managed Care (MC) to Fee for Service (FFS), beginning April 1, 2023. The transition of pharmacy benefits from Managed Care to FFS applied to 5.3 million Medicaid members enrolled in Mainstream Managed Care (MC) Plans, Health and Recovery Plans (HARPs) and HIV-Special Needs Plans (HIV-SNPs). Managed Long Term Care plans (e.g., PACE, MAP, MLTC) and the Essential Plan are not included.

Covered Prescription and Over-the-Counter (OTC) Drugs

NYRx has a list of covered drugs, which include over-the-counter drugs. Use the drug search tool to check if your prescription or OTC is covered.

Preferred Drugs

NYRx has a preferred drug list. If you need a non-preferred drug:

  • Your doctor can ask Medicaid for approval; or
  • Your doctor or pharmacist can find a preferred drug that is right for you and does not require approval.

Covered Supplies

Your pharmacy benefit under NYRx covers certain medical supplies. Some durable medical equipment (DME), such as wheelchairs, may not be on the NYRx list because they are covered by Medicaid as a medical benefit.

NYRx also has a list of preferred diabetic supplies under the Preferred Diabetic Supply Program (PDSP).

Copayments

Your copayment might be different depending on if the drug is preferred or non-preferred. Please review the benefits and coverage information about copayments.

Most pharmacies in New York State take NYRx. You can check by using the pharmacy/supplier search tool. The user guide has step by step instructions about how to use the tool.

If your pharmacy does not take NYRx:

  • Ask your pharmacist to transfer your prescription to a participating pharmacy; or
  • Ask your doctor to send your prescription to a participating pharmacy.