By the Legal Aid Society

This guide will answer common questions about New York State’s new Medicaid pharmacy benefits program, NYRx, which took effect April 1st, 2023.

How does NYRx work?

Through NYRx, New York State Medicaid will now pay for your drugs and medical supplies when you are at the pharmacy. Your health plan will no longer be paying for these benefits.

Am I affected by this pharmacy benefit transition?

If you are currently enrolled in a Mainstream Medicaid Managed Care Plan, a Health and Recovery Plan (HARP), or an HIV Special Needs Plan (HIV-SNP), you are automatically enrolled in NYRx. If you are enrolled in a Managed Long-Term Care Plan (MLTC), Medicaid Advantage Plus (MAP), Program of All-Inclusive Care for the Elderly (PACE), an Essential Plan (EP), or Child Health Plus (CHP), then NYRx does not apply to you.

What does the NYRx pharmacy benefit include/cover?

NYRx will cover the following:

• Prescription drugs and select non-prescription over the counter (OTC) medications listed on the Medicaid List of Reimbursable drugs. The list of covered drugs can be found here. Some drugs need prior approval or authorization (PA) before they can be filled. This list will tell you if a drug needs prior approval. If so, your doctor will call to get prior approval. If your drug is not on this list, your doctor can ask Medicaid for approval to let you get the drug, or your pharmacist can talk to your doctor about changing the prescription to a drug that is on the list.
• Durable Medical Equipment (DME), including Family Planning and medical/surgical supplies. A list of covered supplies can be found here.
• Insulin and diabetic supplies. A list of preferred diabetic meters and test strips can be found here. Medicaid will allow a one-time only fill from April 1, 2023, through June 30, 2023, for non-preferred test strips.
• Pharmacist administered vaccines.

Does NYRx honor my existing Prior Authorizations or Approvals (PAs)?

Yes. PAs issued by Medicaid Managed Care plans prior to April 1, 2023 (that are active/valid after April 1, 2023) will be honored and transferred to NYRx. If there is an issue at the pharmacy for a drug or supply that has already been approved, ask the pharmacist to call the Magellan call center at 877-309-9493

Can I get a prescription or supply fill without a Prior Authorization (PA)?

Yes. From April 1, 2023, through June 30, 2023 you may receive a one-time, temporary fill for up to a 30-day supply of a drug that would normally require PA under NYRx. If there is an issue at the pharmacy with obtaining the fill, you should ask the pharmacist to call the Magellan call center at 877-309-9493. After receiving a one-time temporary fill for a non-preferred drug or supply, you must talk to your prescribing doctor or pharmacist about either submitting a request for PA to NYRx or switching to an alternate drug or supply that does not require PA.

What happens if my Prior Authorization or Approval (PA) is denied under NYRx?

Under NYRx your doctor (the prescriber) has the final say with respect to PAs. For example, if your doctor determines that use of a prescription drug is warranted, your doctor’s determination is final. This applies for every drug category; however your doctor will still be required to provide NYRx with the information and/or clinical documentation required for PA requests.

Is it possible to receive an emergency fill or refill without prior authorization?

If you have a valid prescription, pharmacists may provide up to a 3-day emergency supply of medication by completing the emergency authorization process. You may tell the pharmacist to call the Magellan call center 877-309 9493 for assistance.

How do I know if my pharmacy is participating in NYRx?

Most pharmacies in New York State participate in NYRx. You can locate NYRx-participating pharmacies here. If your pharmacy does not take Medicaid, you may ask your doctor to send a new prescription or transfer a refill to a pharmacy that participates in NYRx.

Do I need a new pharmacy benefits card?

No. To obtain medication, you may present your Common Benefit Identification Card (CBIC), also known as your New York State (NYS) Benefits Identification Card. You may also show your Medicaid health plan card. Both cards have your CIN (client identification number), which the pharmacist will use to bill NYRx for your drugs and/or supplies.
NOTE: If you receive cash assistance and/or SNAP (also known as food stamps), you use your NYS Benefits Identification Card for those benefits as well. The NYS benefits card looks like this:

Health plan cards look like this:

Will my co-payments for OTC drugs, prescriptions, or DME change?

No, your co-payments will not change. All co-payments will stay the same:

•  $3.00 for non-preferred Brand Name Drugs.
• $1.00 for Generic Drugs, preferred Brand Name Drugs, and Brand Drugs included in the Brand Less than Generic Drugs Program.
• $0.50 for Non-Prescription OTC Products.
•  $1.00 for Medical Supplies, including DME. DME is also covered by DME distributors.

What if I am in the Restricted Recipient Program (RRP)?

If you were a member of the RRP prior to April 1, 2023, you will remain restricted for services under NYRx. RRP members will continue to coordinate changes on their restrictions as they relate to pharmacy benefits through the New York City Human Resources Administration (HRA) Recipient Restriction (RR) unit. Changes related to your restriction to a pharmacy, if appropriate, will be processed by the HRA RR staff.

Get Help

For more information, you may call the NYRx Medicaid Helpline at 855-648-1909 (800-662-1220 TTY), Mon – Fri 8 am – 8 pm and Sat 9 am – 1 pm or email NYRx@health.ny.gov. If you require legal assistance with your individual case, you may call The Legal Aid Society’s Access to Benefits helpline at 888-663-6880.

Disclaimer

The information in this document has been prepared by The Legal Aid Society for informational purposes only and is not legal advice. This information is not intended to create, and receipt of it does not constitute, an attorney-client relationship. You should not act upon any information without retaining professional legal counsel.