MedicaidAdministrativeHigh impact
Transition of Pharmacy Benefit from Managed Care to Fee-for-Service
Healthfirst·NY·Pharmacy
We identified it
Jun 20, 2026
Summary
Medicaid members in MMC, HARPs, and HIV-SNPs will now receive pharmacy benefits through the NYRx program instead of their managed care plans. This represents a shift from managed care pharmacy coverage to fee-for-service pharmacy benefits for specific Medicaid plan types.
Action Required
Immediately: Billing team must verify pharmacy benefit coverage source for Medicaid MMC, HARP, and HIV-SNP members. Update patient insurance verification procedures to check NYRx pharmacy program eligibility rather than managed care pharmacy benefits. Contact NYRx program for specific billing procedures and requirements. Members in MLTC, Essential Plans, or Child Health Plus are not affected.