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NYRx Pharmacy Drug Coverage: Claims Processing Enhancements and Reminders
Act
immediately
Effective date
Not stated in the notice
Identified
May 10, 2026
Summary
NYRx Pharmacy has implemented enhanced claims processing edits for NYS Medicaid to reject non-covered drugs including those lacking federal rebate agreements, excluded from state plan coverage (weight loss, sexual dysfunction, cosmetic drugs), terminated NDCs, DESI-flagged drugs, and medical supplies billed with NDC instead of procedure codes. Billing teams must identify rejection codes (00551, 02351, 02352, 02353, 02354, 01600) and resolve claims by consulting the eMedNY Medicaid Pharmacy List of Reimbursable Drugs for covered alternatives.
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What to do
immediately · 9 steps
01Billing and pharmacy teams must implement the following processes.
02Train staff to recognize six claim rejection edit codes (00551, 02351, 02352, 02353, 02354, 01600) and their causes.
03When NYRx pharmacy claims are rejected, consult the eMedNY 'Medicaid Pharmacy List of Reimbursable Drugs' web page to identify covered NDC alternatives before resubmitting.
04For rejected drugs without federal rebate agreement participation, contact prescribers to request alternative covered medications.
05For weight loss drugs (e.g., Zepbound, Wegovy), cosmetic/hair growth drugs, sexual dysfunction drugs, and anorexia treatments—do NOT bill NYRx; these are never covered per federal law.
06When submitting durable medical equipment or medical supplies claims, use HCPCS procedure codes from NYS DME guidelines instead of NDC numbers; NDC submission will trigger rejection code 02354.
07Flag terminated NDCs (rejection code 01600) and replace with current alternatives from the eMedNY list.
08Update billing system rules and claim scrubbing logic to catch these scenarios before submission.
09Contact NYRx@health.ny.gov for coverage questions or eMedNY Call Center (800) 343-9000 (Mon–Fri 7am–10pm, Sat–Sun 8:30am–5:30pm EST) for billing support.
If missed: Failure to follow these steps will result in systematic claim denials and delayed patient access to medications.
Original notice
NYRx Pharmacy Drug Coverage: Claims Processing Enhancements and Reminders
health.ny.gov · Always check the source before changing claims.