Legislation allows a medical practitioner/prescriber in limited circumstances to label and dispense prescription drugs directly to their patient for at-home self-administration. A medical practitioner/prescriber, practicing within their scope of practice, that dispenses prescription medications directly to their patient is not considered a pharmacy, and therefore is NOT eligible for Medicaid enrollment or reimbursement as a pharmacy provider.
As of September 1, 2022, medical practitioners that choose to dispense prescription medications to their patients will only be eligible to bill these medications via a medical claim format and will be reimbursed at actual invoice cost for the drug dispensed. Medical practitioners may not submit an office visit claim for the sole purpose of dispensing a drug that the member can obtain at a NYS Medicaid enrolled pharmacy.
NYS Medicaid enrolled practitioners are eligible to bill medications dispensed to a patient via the medical claim format. Practitioners submit using an appropriate Healthcare Common Procedure Coding System (HCPCS) code and corresponding National Drug Code (NDC) when billing for a medication for which they have dispensed. If a specific HCPCS code has not been assigned for an oral medication, the following codes may be utilized:
- "J8999" - Rx Drug Oral Chemotherapy
- "J8499" - Rx Drug Oral Non-Chemotherapy
To determine if prior authorization is required, please refer to our authorization grids found at: https://www.fideliscare.org/Portals/0/Providers/Authorization-Grid-Medicaid-CHP-HARP-October-2022.pdf
Oncology medications and supportive agents will require prior authorization (PA) from New Century Health. Requests can be submitted by visiting NCH’s Web portal at my.newcenturyhealth.com or calling 1-888-999-7713, option 1.
For the list of drugs that require NCH review, please check the website at: https://www.fideliscare.org/Portals/0/Providers/PharmacyServices/2022-New-Century-Health-Oncology-Program-Medicaid-HARP.pdf