MedicaidPrior AuthMedium impact
NYRx Pharmacy Drug Coverage: Claims Processing Enhancements and Reminders
NY Medicaid·NY · Gastroenterology, Family Medicine, Internal Medicine·Pharmacy
Effective date
Jan 1, 2026
We identified it
May 10, 2026
Summary
New York State Medicaid has updated prior authorization requirements for pharmacy claims, prohibiting third-party entities from submitting PA requests and clarifying that only prescribers or their authorized agents may request prior authorizations. The policy also provides updated coverage criteria for wireless capsule endoscopy procedures.
Action Required
Immediately: Review current prior authorization workflows to ensure only prescribers or their authorized agents (employees with access to patient medical records) are submitting PA requests. Stop any third-party PA submission arrangements. For wireless capsule endoscopy, verify procedures meet new coverage criteria before billing CPT codes 91110 and 91111. Document medical necessity and retain records for minimum 6 years.