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Pharmacy Benefit Transition

Effective April 1, 2023, NYS Medicaid members enrolled in mainstream Medicaid Managed Care (MMC) Plans, Health and Recovery Plans (HARPs), and HIV-Special Needs Plans (SNPs) will receive their pharmacy benefits through the NYRx Pharmacy program instead of through their MMC Plan. The pharmacy benefit transition to NYRx does not apply to NYS Medicaid members enrolled in Managed Long-Term Care (MLTC) Plans [e.g., MLTC, Programs of All-Inclusive Care for the Elderly (PACE), Medicaid Advantage Plus (MAP), the Essential Plan, or Child Health Plus (CHP)]. Transitioning the pharmacy benefit from MMC to NYRx will provide NYS with full visibility into prescription drug costs, allow centralization of the benefit, leverage negotiation power, and provide a uniform list of covered drugs with standardized utilization management protocols simplifying and streamlining the drug benefit for NYS Medicaid members. NYS Medicaid consumers have comprehensive drug coverage and equitable access to an extensive network of over 5,000 pharmacy providers.

Providers, including prescribers, pharmacies and DMEPOS providers, must be enrolled in NYS Medicaid to receive reimbursement for services provided to Medicaid members. See provider enrollment for more information.

Failure to enroll will result in denial of claims for prescriptions, effective April 1, 2023.

For information about enrollment exceptions, please review the Pharmacy Billing Guidance Exceptions for Non-Enrolled Prescribers in Medicaid.

For more information about the transition, please visit the NYRx pharmacy benefit transition website or see the Useful Links section on the right side of this page.

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