NYS Medicaid Managed Care Pharmacy Benefit Information Center
Effective April 1, 2023 the pharmacy benefit for New York State Medicaid Managed Care members will be transitioned to NYRX,
the Medicaid Pharmacy Program formerly known as Medicaid Fee-for-Service.
For detailed information about this transition please visit the NYRx pharmacy benefit transition
Providers, including Pharmacies, Durable Medical Equipment, Prosthetic, Orthotic and Supply Providers and Prescribers,
must be enrolled in NYS Medicaid to provide services to Medicaid members. Please visit
eMedNY Provider Enrollment
To find out if a covered drug has limited strengths on formulary or other requirements such as step therapy, quantity limits and/or prior authorization requirements, please click on the "C" to view the results. To limit the health plans displayed, scroll
down to the bottom of the page to customize your results.
UPPERCASE indicates brand name drug, lowercase indicates generic name drug, C=Covered, NC=Not Covered
To help assist providers with Hepatitis C prior authorization (PA) criteria the following
has been provided. This
contains clinical criteria commonly requested through the PA process. Requirements may vary by plan.
Important Coverage Notes Regarding Results of Drug Look-Up Function:
Results reflect coverage under the Medicaid Managed Care plan's outpatient pharmacy benefit and may include drugs that are only available through a plan's Specialty Pharmacy Network. Refer to plans' website for specific
Results are not inclusive of all covered practitioner administered or certain over-the-counter drugs and or supplies. Additional drugs may be covered as a medical benefit. Please refer to the plan's website for more detailed information on physician administered
drugs available as a medical benefit.
Coverage of Injectable Antipsychotics and naltrexone (Vivitrol®)
for members age 20 or younger that qualify for Social Security Income (SSI) or are SSI related
will continue to be provided by Medicaid FFS as a Medical Benefit only until they transition
into Medicaid Managed care.
For more information about the behavioral health benefit transition to
Medicaid Managed care please see the please see our FAQ page.
Please note, the drug look-up reflects drug coverage under the pharmacy benefit of each plan
(which may include specialty pharmacy drugs).
It is not inclusive of all covered practitioner administered or certain over-the-counter drugs and or supplies.
Additional drugs may be covered under the medical benefit of each plan.
Please refer to the plans' website for more detailed information on physician administered drugs
available under the medical benefit.
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The New York State Department of Health (NYSDOH) obtains drug formulary information from Medicaid participating managed care plans on a quarterly basis. Please note NYSDOH publishes the drug formulary information as it is received. This information was
last updated on
2023-01-20. As a best practice, always contact or visit your managed care plan's website to obtain the most current information regarding drug coverage.