Notice: Medicaid Prescription Drug Benefit Changes Effective April 1, 2023
2/15/2023
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Posted by Provider Relations
Effective April 1, 2023, Medicaid members enrolled in Fidelis Care Managed Care Plans, Health and Recovery Plans (HARPs), and HIV-Special Needs Plan (SNPs) will begin to receive their pharmacy benefits through NYRx, the Medicaid Fee-for-Service (FFS) Pharmacy Program. The transition does not apply to members enrolled in Managed Long-Term Care plans, the Essential Plan, or Child Health Plus (CHP).
Moving all Medicaid members to the NYRx Program allows for a single, uniform list of covered drugs and standardized, consistent rules and regulations. Medicaid members will have comprehensive drug coverage and equitable access to an extensive network of over 5,000 pharmacy providers.
- Pharmacy Procedures and Supply Codes lists supplies subject to the transition from Fidelis Care to FFS, such as enteral and parenteral nutrition, family planning and medical/surgical supplies.
- Durable Medical Equipment, Prosthetics and Supplies Manual lists items that are not subject to the transition in Sections 4.4, 4.5, 4.6, and 4.7. These items, which include durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), will remain the responsibility of Fidelis Care.
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Pharmacy Services
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Current State
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Future State (as of 4/1/2023)
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Managed Care Delivery System
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Pharmacy benefits that are billed on pharmacy claims
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Fidelis Care is responsible for providing these benefits
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Fidelis Care will no longer be responsible for those items identified as being subject to the FFS transition
These claims will be processed under FFS and paid through the eMedNY system.
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Pharmacy benefits that are billed on medical and institutional claims
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Fidelis Care is responsible for providing these benefits
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No change
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FFS Delivery System
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Pharmacy benefits that are billed on pharmacy claims
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Processed and adjudicated through eMedNY
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No change
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Pharmacy benefits that are billed on medical and institutional claims
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Processed and adjudicated through eMedNY
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No change
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Member Notification:
Beginning this month, members will begin receiving letters in the mail from Fidelis Care informing them about the pharmacy benefit transition to NYRx effective April 1, 2023.
The letters include information about:
- Member ID card to show the pharmacy (either NYS benefit card or Fidelis Care plan card)
- NYRx coverage of drugs and supplies
- April 1 – June 30, 2023 transition period for one-time fill of non-preferred products without prior authorization
- Resources, including the Medicaid Helpline and eMedNY member website
Educational Opportunities:
The New York Department of Health will be hosting a monthly webinar about the pharmacy benefit transition. Members, providers, and all interested stakeholders are welcome to attend. Registration information will be posted one week prior to each webinar date.
Upcoming Webinar Dates:
- February 21, 2023 at 1:00 PM
- March 21, 2023 at 1:00 PM
- April 18, 2023 at 1:00 PM
Presentations from past meetings are available in the Document Repository.
If you have any questions, please email NYRx@health.ny.gov, or contact your local Provider Relations Specialist.