MedicaidPrior AuthHigh impact
One New Reimbursement Policy: Medicaid – NYRx Pharmacy Program
EmblemHealth·NY · Pharmacy·Pharmacy
Effective date
Jan 1, 2026
We identified it
Jul 17, 2026
Summary
EmblemHealth has established a formal reimbursement policy for New York State Medicaid (NYRx) pharmacy program claims, including physician-administered drugs (PADs). Effective January 1, 2026, specialty drugs requiring prior authorization must be submitted through Prime Therapeutics (gatewaypa.com or 833-519-4548). All outpatient pharmacy claims must include valid HCPCS/CPT procedure codes paired with appropriate revenue codes or will be denied and returned for resubmission.
Action Required
By December 31, 2025: (1) Billing team must establish workflow for obtaining prior authorization for select specialty drugs through Prime Therapeutics Medical Pharmacy Solutions via gatewaypa.com or 833-519-4548 before January 1, 2026. (2) Verify current billing software can enforce requirement that all outpatient UB-04 claims for NYRx Medicaid members include both valid HCPCS/CPT procedure codes AND appropriate revenue codes before claim submission. (3) Providers and billing staff must review the complete NYRx program billing guidelines available in the policy resources section and ensure all team members understand the revenue code requirements. (4) Update internal claim submission checklists to flag NYRx Medicaid claims for verification of proper code combinations. Consequence: Claims submitted without required HCPCS/CPT codes or with invalid code-revenue combinations will be denied and returned for resubmission, delaying reimbursement.