The Following Guidance Supersedes Previous Communications on this Topic
New York State Education (NYSED) Law, Article 137 §6807, authorizes practitioners, who are authorized to prescribe, to dispense medications directly to their patients. Additional registration or ownership of a pharmacy is not required. This dispensing must be done in accordance with federal, State, and New York State (NYS) Medicaid program policies for dispensing, billing, and record keeping.
The NYS Medicaid program reimburses for drugs furnished by practitioners to their patients on the basis of the acquisition cost to the practitioner of the drug dose provided to the patient. For all drugs dispensed to the patient, regardless of whether an invoice must be submitted to NYS Medicaid for payment, the practitioner must, and is expected to, maintain auditable records of, and limit his/her claim amount to, the actual itemized invoice cost of the drug dispensed. 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.
FFS Billing
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
Please note: The use of the codes provided above will require invoice and policy criteria verification. Policy and billing guidelines can be found on the eMedNY “Physician Manual” web page.
MMC Billing
A practitioner participating in Medicaid Managed Care (MMC) should check with the patient’s health plan to determine the plan billing policy for prescription drugs dispensed directly to a patient.
Reminder: A practitioner that dispenses prescriptions directly to their patient are not considered a pharmacy and, therefore, is not required to be enrolled as a pharmacy provider.
Questions and Additional Information
Medicaid fee-for-service (FFS) claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
Medicaid FFS coverage and policy questions should be directed to the Office of Health Insurance Programs (OHIP) Division of Program Development and Management (DPDM) by telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
Medicaid FFS Pharmacy coverage and policy questions should be directed to the Medicaid Pharmacy Policy Unit by telephone at (518) 486-3209 or by email at PPNO@health.ny.gov.
MMC general coverage questions should be directed to the OHIP Division of Health Plan Contracting and Oversight (DHPCO) by email at covques@health.ny.gov or by telephone at (518) 473-1134.
MMC reimbursement, billing, and/or documentation requirement questions should be directed to enrollee MMC Plans.
MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers Managed Care Information document.
MMC plan-specific policies and billing guidance for PADs can be found on the NYS DOH “New York State Medicaid Managed Care (MMC) Pharmacy Benefit Information Center” website.