Health Equity

To help prevent claim denials and payment recoupments, Fidelis Care would like to remind providers of billing requirements for practitioner‑administered drugs (PADs) that are covered under the NYRx pharmacy benefit.

Certain PADs are included on the Medicaid Pharmacy List of Reimbursable Drugs and may be billed directly to NYRx by a pharmacy. When these drugs are obtained through the NYRx Program—or provided at no cost—providers may not submit a medical claim for reimbursement of the drug itself.

Providers may only seek reimbursement for the administration of a no‑cost drug. PADs obtained via NYRx and billed to Fidelis as a medical claim will be denied. In addition, any payments issued by Fidelis that do not comply with these requirements may be subject to recoupment.

We encourage providers to review their billing processes to ensure claims are submitted correctly and in accordance with NYRx and Fidelis Care guidelines. Accurate billing helps avoid delays, denials, and potential recoveries.

For questions or additional guidance, please refer to the NYRx Program Resources or contact your Provider Engagement Account Manager.  To find your designated representative, visit www.fideliscare.org/Provider/Contact-Provider-Relations.