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Change in Pharmacy Benefit for Medicaid Managed Care Members

Audience: Durable Medical Equipment Providers

As you may know, effective April 1, 2023, pharmacy benefits for Medicaid Managed Care and Health and Recovery Plan (HARP) members are covered under Medicaid Fee for Service (NYRx) and not by Univera Healthcare. Effective April 1, you must bill NYRx directly for these services. New York state has indicated that moving all Medicaid consumers under the NYRx Program allows for a single, uniform list of covered drugs and standardized, consistent rules and regulations.

Preauthorization for Medical Surgical Supplies and Enteral/Parenteral Nutrition Formula:

  • Health Plan authorizations issued prior to April 1, 2023, for pharmacy point-of-sale transactions will be recognized by NYRx. The Health Plan will provide prior authorization history to the New York State Department of Health. No action is required on your part to transition the authorization to New York state. 
  • Health Plan authorizations issued prior to April 1, 2023, for services billed to the Health Plan as a medical or institutional claim and subject to transition to NYRx Program will not be recognized by New York state.  DMEPOS providers must follow state billing guidance effective April 1, 2023.

Please refer to the Durable Medical Equipment, Prosthetics, Orthotics, Supplies and Procedure Codes and Coverage Guidelines at emedny.org/ProviderManuals/ for more specific guidance. Items included in sections 4.1, 4.2, and 4.3 are subject to the transition while sections 4.4, 4.5, 4.6, and 4.7 will remain the responsibility of the Health Plan.

For further information including contact information after April 1, 2023, please visit: https://www.health.ny.gov/health_care/medicaid/program/update/2022/no11_2022-10_speced.htm or contact .

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