Since July 15, 2025, NYRx, the New York State Medicaid Pharmacy Program, has accepted electronic prior authorization (ePA) requests through CoverMyMeds, in addition to the existing phone and fax channels. For prescribers, this means a faster and more trackable way to obtain approvals for medications that require prior authorization. For pharmacies, it creates a convenient workflow, but also a compliance line that must not be crossed.
How the CoverMyMeds Workflow Operates for NYRx
Under the NYRx guidance, prior authorization requests must be submitted by the prescriber. A pharmacy using CoverMyMeds may initiate an ePA on the member's behalf when a claim rejects for prior authorization, but the request is then routed to the prescriber's CoverMyMeds queue. The prescriber, or an authorized agent working in the prescriber's practice, must complete the clinical information and submit the request to NYRx. Agent profiles should be validated with the prescriber's NPI.
Third-Party Prior Authorization Requests Are Prohibited
New York Medicaid has repeatedly warned that third-party prior authorization requests are prohibited. Only the prescriber, or an agent who works in the same practice and has access to the patient's medical record (such as a nurse or medical assistant), may submit a PA request. Pharmacies may not offer to obtain prior authorizations for prescribers, and pharmacists may not submit PA requests or appeals on a prescriber's behalf, including under an informal arrangement with the prescriber's office.
The consequences are serious. Pharmacies and practitioners found engaging in this conduct may face termination or exclusion from the New York Medicaid program, and conduct involving inaccurate clinical information can also lead to audit findings, recoupment, and False Claims Act exposure.
Practical Steps for Pharmacies
Use CoverMyMeds to initiate and route ePA requests to the prescriber, but never complete clinical fields or submit on the prescriber's behalf.
Train staff not to identify themselves as the prescriber's office or to complete PA forms for prescribers.
Document each ePA you initiate and when it was routed to the prescriber, so your role is clear in the event of an audit.
Review written policies and PBM contract requirements governing prior authorization support.
MDRXLaw represents pharmacies in Medicaid compliance matters, OMIG and PBM audits, and enrollment proceedings. If you have questions about prior authorization workflows or have received an audit or inquiry, contact our healthcare attorneys at 212.668.0200 or info@mdrxlaw.com.
