Billing Physician Administered Drugs

On April 1, 2023, the prescription drug benefit for all New York State (NYS) Medicaid members enrolled in a Mainstream Managed Care Plan (MCP), Health, and Recovery Plan (HARP), and HIV Special Needs Plan (HIV-SNP) was transitioned to NYRx, the Medicaid Pharmacy Program. The transition did not change the MCP’s responsibility for coverage of certain drugs billed on medical claims. For more information, review the Transition of the Pharmacy Benefit from Managed Care to Fee-for-Service provider alert.

Healthfirst Responsibility for Physician Administered Drugs and the NYRx Program

The pharmacy benefit transition included outpatient drugs and other products covered under the Medicaid Pharmacy Program. Physician administered drugs (PADs) when administered by a physician or other practitioner in an appropriately licensed outpatient setting and billed on the professional claim form (1500 or 837P), continue to be covered by Healthfirst.

• PADs billed by a specialty or home infusion pharmacy will be reimbursed by Healthfirst as a medical claim if the PADs are present on the NYRx Medicaid Pharmacy List of Reimbursable Drugs and depending on whether the PADs are given as part of another CPT/HCPCS coded service.
  • For example, PADs and the injection procedure code submitted on the same claim will be reimbursed by Healthfirst.
• PADs billed by a specialty or home infusion pharmacy will not be reimbursed by Healthfirst if the PADs are present on the NYRx Medicaid Pharmacy List of Reimbursable Drugs and an injection procedure code is not submitted on the same claim form.
  • Healthfirst will deny these claims and refer to the NYRx Program as the responsible payer.
• PADs which are not present on the NYRx Medicaid Pharmacy List of Reimbursable Drugs billed by a specialty or home infusion pharmacy will continue to be reimbursed by Healthfirst.

As a reminder, brown bagging (PADs dispensed directly to a patient by the pharmacy to bring to their practitioner’s office for administration) is not acceptable under the NYS Medicaid program.

For more information on obtaining PADs through a specialty pharmacy and white bagged drugs, please review the corresponding provider alert here.

Prevention of Duplicate Billing of Physician Administered Drugs: Medical Benefit and the NYRx Program

Certain practitioner-administered drugs are listed on the Medicaid Pharmacy List of Reimbursable Drugs and may be billed directly to NYRx by a pharmacy.

Practitioners in a private practice setting that administer drugs covered through the pharmacy benefit, and/or obtained at no-cost, may only seek reimbursement for the administration of the no-cost drug when the service is performed as part of an office visit. For more information on obtaining PADs through a specialty pharmacy and proper billing procedure, please review the corresponding provider alert here.

PADs which are obtained via the NYRx Program and billed as a medical claim for reimbursement will be denied by Healthfirst.

Any payments issued by Healthfirst not in accordance with requirements noted above may be subject to recoupment.

More Information

• Medicaid Pharmacy List of Reimbursable Drugs
• Healthfirst Provider Alert: Transition of the Pharmacy Benefit from Managed Care to Fee-for-Service
• Healthfirst Provider Alert: Obtaining Physician Administered Drugs through a Specialty Pharmacy

Questions?

If you have any questions, please contact your Network Account Manager, or call Provider Services at 1-888-801-1660, Monday to Friday, 8:30am-5:30pm

Coverage is provided by Healthfirst Health Plan, Inc., Healthfirst PHSP, Inc., and/or Healthfirst Insurance Company, Inc. (together, “Healthfirst”).
Released December 2025