Introducing NYRx + Changes for Filling Prescriptions for Mainstream Medicaid Managed Care Enrollees
NYRx is the new name for New York State’s Medicaid Pharmacy Program.
Beginning April 1, 2023, pharmacy benefits will be “carved out” of the benefits package for Mainstream Medicaid Managed Care plans (MMC), Health and Recovery Plans (HARPs) and HIV-Special Needs Plans (HIV-SNPs).This means that plan members will no longer have their prescriptions covered by their managed care plan. Instead, NYRx, New York’s Medicaid Pharmacy Program, will cover these drugs.
This transition does not apply to members of Managed Long Term Care plans (including PACE, MAP and MLTC), Child health Plus, or the Essential Plan.
There are no changes to cost sharing for beneficiaries; the only change relates to who pays for prescriptions. Individuals can present either their managed care plan’s card or their Medicaid card at the pharmacy. Most pharmacies will participate in NYRx; a listing of participating pharmacies can be found here.
This change does not affect the way managed care plan members receive durable medical equipment (DME). DME will continue to be covered by the Medicaid managed care plan.
Individuals affected by this change should have received a notice from their plan. If they have any questions, they can call the NYS Medicaid Helpline at (855) 648-1909.
Dual eligibles (individuals with both Medicare and Medicaid) are not affected by this change as they have Medicare Part D coverage (either through a standalone Part D plan, or a Medicare Advantage plan) and fee-for-service Medicaid. To access prescriptions excluded from Medicare Part D (for example, prescription vitamins, cough and cold medications, and benzonatate) and certain over-the-counter (OTC) drugs, dual eligibles can continue to use their Medicaid card.
