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Policy Clarification for Practitioner Medication Dispensing

Audience: Medicaid Enrolled Prescribing Practitioners

Under New York State Education Law, Article 137 §6807, practitioners who are authorized to prescribe can dispense medications directly to their patients. Additional registration or ownership of a pharmacy is not required. This dispensing must be done in accordance with federal, state, and New York State Medicaid program policies for dispensing, billing, and record keeping.

The following guidance is applicable to Medicaid Managed Care (MMC) and Health and Recovery Plan (HARP) lines of business.

MMC/HARP Billing Guidance
Medicaid enrolled practitioners are eligible to bill medications dispensed to a patient via the medical claim format. Practitioners submit using an appropriate Healthcare Common Procedure Coding System (HCPCS®) code and corresponding National Drug Code when billing for a medication they have dispensed. If a specific HCPCS code has not been assigned for an oral medication, the following codes may be used:

  • J8999 – Rx Drug Oral Chemotherapy
  • J8499 – Rx Drug Oral Non-Chemotherapy

Practitioners may not submit an office visit claim for the sole purpose of dispensing a drug that the member can obtain at a New York state Medicaid enrolled pharmacy.

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