One New Reimbursement Policy: Medicaid – NYRx Pharmacy Program

For transparency and clarity on where to submit claims for members covered by the New York State Medicaid Pharmacy Program (NYRx), EmblemHealth has established a formal reimbursement policy called Medicaid – NYRx Pharmacy Program. 

This policy follows the NYRx program’s billing guidelines, including those applicable to physician administered drugs (PADs). For full information about NYRx, see the Resources section of the new policy.

Reminder: Contact Prime Therapeutics Medical Pharmacy Solutions via gatewaypa.com or by calling 833-519-4548 to obtain prior authorization for select specialty drugs that fall under the medical benefit on or after Jan. 1, 2026. See full announcement for details on all Pharmacy services that began in 2026.

Reimbursement Policy Reminder: Revenue Codes Requiring Detailed Coding

Outpatient claims submitted without the required HCPCS and/or CPT procedure code(s), or with invalid HCPCS/CPT and revenue code combinations, will not be paid and will be returned for proper resubmission. Providers should review the applicable revenue code requirements and ensure outpatient UB-04 claims include the appropriate HCPCS/CPT procedure code(s) before submission.