Beginning April 1, 2023, all Medicaid members enrolled in Amida Care will receive their prescription drugs through NYRx, the Medicaid Pharmacy Program.
Information about the transition of the pharmacy benefit from Amida Care to NYRx, the Medicaid Pharmacy Program can be found here
General information about NYRx, the Medicaid Pharmacy Program can be found HERE along with information for members and Providers.
The NYRx preferred drug list, clinical criteria and additional program information can be found at https://newyork.fhsc.com/providers/pdp_about.asp
You may resubmit the claim with a Date of Service on or after 4/1/2023 to NYRx.
If required, providers can request prior authorization by calling the Magellan call center at 1-877-309-9493.
For situations where medically necessary and pursuant to SSL §364-j (25) and (25-a) and Section 10.32 of the Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan/Health and Recovery Model Contract, a 72-hour supply may be provided to the member.
For medications to be administered by a healthcare professional (J-codes), vaccines, and COVID-19 related drugs, please refer to the “Important Updates” section.
Vaccine Coverage
Please see below for Amida Care’s Vaccine Coverage Guidelines. These coverage guidelines detail vaccine coverage for adults and children as well as which location you can receive the vaccine and which vaccines require prior authorization. You can also find updated retail pharmacy instructions for vaccine billing.
Pharmacy Vaccine Billing Process
COVID-19 Information for Providers and Pharmacies
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COVID-19 Vaccine Codes & Coverage
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COVID-19 Vaccines Administration Billing Guidance
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COVID-19 Vaccine Counseling Billing Guidance
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COVID-19 Therapeutics Locator
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COVID-19 Testing and Specimen Collection Billing Guidance for Pharmacies
Governor Executive Order has been implemented to allow pharmacies to be able to bill for COVID-19 testing and sample collection. -
At Home COVID-19 Testing Coverage Policy and Billing Guidance
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Oral Antiviral Treatments for COVID-19 – Emergency Use Authorization
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COVID-19 Monoclonal Antibodies Pharmacy Policy and Billing Guidance for Reimbursement
Misc. Prior Authorization Criteria
Please see below for Amida Care’s Prior Authorization Criteria for miscellaneous agents. These coverage guidelines detail whether the specific agents mentioned will be available through either Amida Care’s pharmacy or medical benefit.
Physician Dispensed Drugs Policy
Non-Enrolled Provider/Pharmacy Overrides
- How to override reject 889 (non-enrolled provider)
- Pharmacy Exceptions Guidance for Non-Enrolled Providers
Medication Assisted Treatment
The Amida Care Medicaid benefits plan offers members a single statewide outpatient formulary for Opioid Dependence Agents and Opioid Antagonists, in accordance with the New York State (NYS) Department of Health Single Statewide (DOH) – Medication Assisted Treatment (MAT) Formulary:
https://newyork.fhsc.com/providers/mat.asp
Please consult this list for the latest information about opioid dependence agents and opioid antagonists.
Vaccine Coverage
Please see below for Amida Care’s Vaccine Coverage Guidelines. These coverage guidelines detail vaccine coverage for adults and children as well as which location you can receive the vaccine and which vaccines require prior authorization. You can also find updated retail pharmacy instructions for vaccine billing.
J-Codes
In most instances, NDC numbers are assigned a CPT or HCPCS code. Most injectable medications begin with a “J.” It is important that claims be submitted with the most accurate information when billing for injectable medications that are administered in the office during a patient’s visit. Please see the attached list of J-Codes that require an authorization through Amida Care. Prior to administering any of the JCODES on the list below complete the prior authorization form for approval for payment.
Behavioral Health Carve-in Benefit
As of October 1, 2015, the Amida Care Medicaid benefits plan offers members additional access to certain Injectable Behavioral Health medications as part of the Qualified Health Plan (QHP). See this chart for important updates.
Opioid & Benzodiazipine Limits
Please consult this list for the latest information about opioid limits.
Please consult this list for the latest information about benzodiazipine limits.
J-Codes: In most instances, NDC numbers are assigned a CPT or HCPCS code. Most injectable medications begin with a “J.” It is important that claims be submitted with the most accurate information when billing for injectable medications that are administered in the office during a patient’s visit. Please see the attached list of J-Codes that require an authorization through Amida Care. Prior to administering any of the JCODES on the list below complete the prior authorization form for approval for payment
Misc. Prior Authorization Criteria: Please see below for Amida Care’s Prior Authorization Criteria for miscellaneous agents. These coverage guidelines detail whether the specific agents mentioned will be available through either Amida Care’s pharmacy or medical benefit.