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NY MedicaidMedicaid · Coverage · Pharmacy · NY · PharmacyMedium impact

NYRx Pharmacy Drug Coverage: Claims Processing Enhancements and Reminders

Effective date
Not stated in the notice
Identified
Oct 31, 2026

Summary

This is a historical policy document (published September 1, 2026, discovered October 31, 2026) detailing NYRx pharmacy claims processing edits and rejection rules for non-covered drugs in New York Medicaid. The document describes existing claim edit mechanics for drugs not on the formulary, lacking federal rebate agreements, identified as DESI drugs, excluded from state plan coverage, or terminated by manufacturers. No new effective dates are stated; the policy reinforces longstanding coverage exclusions and references prior guidance from 2018, 2020, and 2025.

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What to do

Action · 7 steps
01Already effective: This document is historical material (published September 2026, newly discovered October 2026) and describes ongoing NYRx claims processing rules, not future changes.
02Billing team should verify current applicability by consulting the eMedNY 'Medicaid Pharmacy List of Reimbursable Drugs' web page and confirming whether the practice has implemented these claim edit rules in its billing system.
03Key ongoing requirements.
04When submitting medical supplies to NYRx, use 11-digit NDC field format with leading zeros, entering the five-character alpha-numeric HCPCS code (e.g., 'A4670') in the last five spaces of the NDC field per Medical Supply Procedure Codes & Coverage Guidelines.
05Verify all NDCs against the eMedNY reimbursable drugs list before billing to avoid rejections (edit codes 00551, 02351, 02352, 02353, 02354, 01600).
06For drugs listed as frequently rejected (e.g., Vascepa, Xifaxan, Tirosint, Jublia—manufacturers that withdrew from MDRP on or before October 2025), direct providers to manufacturer assistance programs or refer to covered alternatives.
07For current policy updates beyond this September 2026 source, consult the January 2025 and April 2025 issues of the Medicaid Update referenced in the source, or contact NYRx@health.ny.gov.

Codes mentioned

A4670

Original notice

NYRx Pharmacy Drug Coverage: Claims Processing Enhancements and Reminders
health.ny.gov · Always check the source before changing claims.
View original ↗

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NYRx Pharmacy Drug Coverage: Claims Processing Enhancements and RemindersHighNo effective date · PharmacyBrowse every NY Medicaid change in the policy list

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NY Medicaid policiesNY policy changesPharmacyCode A4670

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