Benefits and Coverage
NYRx, the Medicaid Pharmacy Program
Copays
A copay is also known as an out-of-pocket cost. Copays vary by service type. Most prescriptions have a copayment of $3 or less, but if you cannot pay due to hardship, you will still receive the drug.
NYRx copay amounts are as follows:
- $3.00 for non-preferred Brand Name Drugs
- $1.00 for Generic Drugs, preferred Brand Name Drugs, and Brand Drugs included in the Brand Less than Generic Drugs Program
- $0.50 for Non-Prescription (over-the-counter) Products
- $1.00 for Medical Supplies
Q: Are there any copay exemptions?
A: Copays are not needed for certain members and service categories. The claim processing system is set up to tell the pharmacist when a copay does not apply. More information about copay exemptions may be found here in the Coverage and Benefits section.
Q: Is there a maximum copay amount to be paid over a period of time?
A: A member will not pay more than $50 in copays per quarter ($200 per year). This is inclusive of copays for all Medicaid-covered services. If a member meets the $50 maximum before the end of the quarter, they will receive a letter confirming the copay maximum was met and that they are exempt from copay until the beginning of the next quarter. A quarter starts in April, July, October, and January.
More information about Medicaid copays may be found here.
Drug Categories not Coverable by NYRx
The New York State Medicaid Pharmacy program, NYRx, covers medically necessary FDA-approved prescription and non-prescription drugs for Medicaid members.
Certain drugs, drug classes, or reasons for taking a drug are excluded from coverage under federal or state law and regulation. Drugs, drug classes, and reasons for taking a drug that are excluded from coverage include the following:
- Drugs used for the treatment of weight loss, weight gain, or anorexia
- Drugs used in the treatment of sexual dysfunction
- Drugs used for cosmetic purposes or hair growth
Q: My prescription for Wegovy, Ozempic, Qsymia, or Mounjaro is being denied at the pharmacy. What do I do?
A: NYRx covers medically necessary FDA-approved drugs when used for Medicaid-approved reasons. Certain drugs, drug classes, or reasons for taking a drug, including weight loss, are excluded from coverage based on federal and state rules. Ozempic and Mounjaro are covered if being used for diabetes. Weight loss has never been a Medicaid-approved reason for covering a drug. Drugs, including but not limited to Ozempic, Wegovy, Qsymia, and Mounjaro, are not covered by NYRx when prescribed for weight loss.
Q: My doctor gave me a prescription for weight loss, hair loss, etc. drug. Does NYRx cover this?
A: NYRx covers medically necessary FDA-approved drugs when used for Medicaid-approved reasons. Certain drugs, drug classes, or reasons for taking a drug, including for weight loss, cosmetic purposes, or hair growth, are excluded from coverage based on federal and state rules.
Emergency Care
An emergency is an illness, injury, symptom, or condition that would cause serious harm to body parts or functions or serious disfigurement without care right away.
Examples of an emergency are:
- a heart attack or severe chest pain
- bleeding that won't stop or a bad burn
- broken bones
- trouble breathing, convulsions, or loss of consciousness
- when you feel you might hurt yourself or others
- if you are pregnant and have signs like pain, bleeding, fever, or vomiting
- drug overdose
Q: What is covered if I have an emergency outside New York State?
A: Your visit to the Emergency Room is covered. If you are discharged from the emergency room with prescriptions, they must be filled at a NYS Medicaid-enrolled pharmacy.
Enrollment - Healthcare Provider
Federal law requires that your healthcare provider be enrolled in NYS Medicaid to service Medicaid members. However, there are a few reasons why your healthcare provider does not need to be enrolled. For example, if you are seen at an emergency room outside of NY, and the healthcare provider is not enrolled in NYS Medicaid.
Q: Does my healthcare provider have to be enrolled in NYS Medicaid to send a prescription to a pharmacy?
A: Yes, members must obtain a prescription from a Medicaid-enrolled provider and fill the prescription at an NYS Medicaid-enrolled pharmacy.
Enrollment - Pharmacy
Most pharmacies in New York State take NYRx. You can check by using the pharmacy/supplier search tool. The user guide has step-by-step instructions about how to use the tool.
If your pharmacy does not take NYRx:
- Ask your pharmacist to transfer your prescription to a participating pharmacy or
- Ask your doctor to send your prescription to a participating pharmacy.
Q: What if a pharmacy does not take NYRx, the Medicaid Pharmacy Program?
A: If your current pharmacy does not take NYRx, you may:
- Ask your pharmacist to transfer a refill to a participating pharmacy.
- Ask your doctor to send your prescriptions to a participating pharmacy. You can use the website's Find a Pharmacy/Medical Equipment Supplier search option to find participating pharmacies or medical suppliers.
Q: Are my prescriptions covered when using a pharmacy outside New York State?
A: There is limited enrollment for pharmacies located outside of NYS. You may use the search tool located on the eMedNY member website for "Pharmacy and Medical Equipment" to find a pharmacy that is enrolled in NYS Medicaid. We suggest calling the pharmacy ahead of time to confirm they can fill your drugs.
Medicare
An individual is eligible for Medicare if they are 65 or older, younger than 65 with disabilities, or have end-stage renal disease. There are four parts of Medicare coverage:
- Part A - Hospital insurance and associated costs
- Part B - Medical insurance (physician services, lab and x-ray services, outpatient and other services)
- Part C - also known as a Medicare Advantage Plan (offered by private companies approved by Medicare and include Part A and B coverage and most often D coverage)
- Part D - Prescription drug coverage
Q: I'm covered under Medicare and Medicaid. Which do I use to obtain my prescriptions?
A: You should use your Medicare Part D pharmacy coverage. You can also continue to use your Medicare plan's over-the-counter (OTC) card for non-prescription drugs and/or other covered items.
Your Medicare Part D plan covers your prescription drugs. NYRx covers select over-the-counter drugs, prescription vitamins, and prescription cough drugs when they are not covered by Medicare. Check online for the complete list at: Prescription Drugs Covered by NYRx for Dual Eligible Members Effective 10/22/2020
Prior Approval/Authorization
Some drugs need prior authorization before NYRx can cover them. If your drug and/or medical supply requires approval from your doctor, you should:
- Talk to your doctor about requesting approval, or
- Talk to your doctor or pharmacist about an alternate drug and/or medical supply that does not require approval. You can use the Medicaid List of Covered Drugs and Over the Counter (OTC) Products and/or Covered Medical Supplies search options on this website, to find covered products.
Q: I paid cash for a drug that required prior authorization from my doctor. Can I get reimbursed for my drug?
A: Once your doctor has gotten prior authorization (PA), the pharmacy may be able to submit your claim to Medicaid and provide reimbursement to you directly. If you choose to pay out-of-pocket for the drug rather than waiting for the PA, you may not be reimbursed for the medication.
Reimbursement
Member out-of-pocket expenses are only reimbursable by Medicaid for Medicaid covered services when one of these three situations applies:
- Services were provided by a participating or non-participating Medicaid provider during the three-month period before the member submitted an application for Medicaid.
- Services were provided by a Medicaid participating provider between the date the member submitted the Medicaid application until they receive their Medicaid CBIC card. Services provided by non-Medicaid enrolled providers are not eligible for reimbursement once a Medicaid application is submitted.
- Services were provided by a participating or non-participating Medicaid provider, and coverage was denied due to NYS DOH agency error or delay.
Third-Party Coverage
Third Party Coverage or Third-Party Liability (TPL) is referred to as other insurance, such as Medicare, commercial or private insurance, which is typically provided by your or a family member's employer. Medicaid is always the payor of last resort, which means any other active coverage must be billed before billing to Medicaid.
Members must present all insurance cards to your pharmacy or healthcare provider when obtaining services.
Travel and 90-Day Supplies
Medicaid ensures an ample drug supply to accommodate most temporary absences. Medicaid does not provide additional drug supplies for a vacation or a temporary absence. Members should prepare before travel by speaking to their pharmacist and physician to ensure they have the drugs and supplies needed for a temporary absence.
Members should be advised: NY Medicaid provides services in the geographic area of the state by NY Medicaid enrolled providers. Members who travel out of state may incur out-of-pocket costs that are not reimbursable. See the 'Reimbursement' section above for the circumstances that qualify for reimbursement.
Q: How should I ensure I have enough of my medication(s) for my short-term travel?
A: NYS Medicaid ensures a sufficient supply of medication(s) to accommodate most temporary absences and allows a 90-day supply for most maintenance medications.
- A member may request a 90-day prescription from their doctor.
- A member may request an early refill up to seven days earlier, depending on the drug and fill history.
- A member can make alternative arrangements by asking the pharmacy to mail the drug to your temporary location.
Q: Does my NYRx benefit pay for a 90-day medication supply?
A: Yes, most medications you take on a regular basis for continuing conditions are available as a 90-day supply.
Vaccines
Vaccines are available to all Medicaid members at no cost.
Members over the age of 18 can obtain certain vaccinations directly at the pharmacy. Members younger than 19 years of age can receive all their vaccines from their pediatrician's office or the local health department.
A full list of vaccines covered by NYRx through the pharmacy benefit can be found on the New York State Medicaid Pharmacists as Immunizers Fact Sheet, located here.
Q: My pharmacy cannot administer my child's vaccination. What do I do?
A: Your child can receive all vaccinations from their pediatrician. If you are experiencing an issue obtaining a vaccination from the pediatrician's office, please email the Bureau of Immunizations at bureau.of.immunization@health.ny.gov, with the name of the child's pediatrician. Meanwhile, if the pediatrician does not have a supply, or those appointments are not timely, we recommend obtaining the vaccine at the local Health Department. A directory for the Departments can be found here.