Summary
Effective November 19, 2026, New York State Medicaid will require prior authorization (PA) for select practitioner-administered drugs (PADs) across five drug classes: botulinum toxin agents (Botox, Dysport, Myobloc, Xeomin, Daxxify), infliximab agents (Remicade and biosimilars), esketamine nasal spray (Spravato), nusinersen (Spinraza), and DMD treatments (Amondys 45, Exondys 51, Viltepso, Vyondys 53). Additional PADs will be added in coming months per NYS Department of Health guidance.
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What to do
by Nov 19, 2026 · 5 steps
01Billing team must implement prior authorization workflow for all practitioner-administered drugs in the five specified drug classes.
02Update billing system to flag claims for onabotulinumtoxinA (Botox), abobotulinumtoxinA (Dysport), rimabotulinumtoxinB (Myobloc), incobotulinumtoxinA (Xeomin), daxibotulinutoxinA (Daxxify), infliximab, infliximab-abda, infliximab-axxq, infliximab-dyyb (both Inflectra and Zymfentra), esketamine nasal spray (Spravato), nusinersen (Spinraza), casimersen (Amondys 45), eteplirsen (Exondys 51), viltolarsen (Viltepso), and golodirsen (Vyondys 53) as requiring PA before claim submission.
03Notify providers to submit prior authorization requests before administering these drugs.
04Claims submitted without prior authorization will be denied by NY Medicaid.
05Monitor the NYS Department of Health website regularly for additional PADs to be added to the requirement list and update workflows accordingly.
Original notice
PADs Requiring PA
health.ny.gov · Always check the source before changing claims.