Pharmacy Services

Click the categories below for important pharmacy documents and resources. 

Formularies
Child Health Plus (CHP), HealthierLife (HARP), and Medicaid Managed Care

2018 Formulary (PDF)

Quick reference list (PDF)


Metal-Level Products

2018 Formulary (PDF)

2017 Formulary (PDF)


Essential Plan

2018 Formulary (PDF)

2017 Formulary (PDF)

Metal-Level Products and Essential Plans Formulary Changes: Effective January 1, 2018 (PDF)


Fully Integrated Duals Advantage (FIDA), (Medicare-Medicaid Plan [MMP]) Formulary

2017 Formulary (PDF)

 

 

Code Type

Code

Effective*

Testing (CDC)

U0001

2/4/2020

Testing (Non-CDC)

U0002

2/4/2020

Testing (Industry Standard)

87635

3/13/2020

Testing (Infectious Disease)

0202U

5/20/2020

Testing (Throughput)

U0003

4/14/2020

Testing (Throughput)

U0004

4/14/2020

Testing (Antigen)

0223U

6/25/2020

Testing (Antigen)

0224U

6/25/2020

Testing (Infectious Disease)

0225U

8/10/2020

Testing (sVNT)

0226U

8/10/2020

Testing

86413

9/8/2020

Testing (Infectious Disease)

0240U

10/6/2020

Testing (Infectious Disease)

0241U

10/6/2020

Testing (Infectious Agent Detection)

87636

10/6/2020

Testing (Infectious Agent Detection)

87637

10/6/2020

Testing (Infectious Agent Detection)

87811

10/6/2020

Mutation identification SARS CoV-2

87913

2/21/2022

Testing (Add-On Payment)

U0005

1/1/2021

OTC At Home COVID Tests

N/A

1/15/2022

Screening

Z03.818

2/4/2020

Screening (Specimen Transfer)

G2023

3/1/2020

Screening (Specimen Transfer)

G2024

3/1/2020

Screening (Specimen Transfer)

C9803

3/1/2020

Screening (Antibody Testing)

86328

4/10/2020

Screening (Antibody Testing)

86769

4/10/2020

Screening (Antigen Detection)

87426

6/25/2020

Screening (Antigen Detection)

87428

11/10/2020

Screening (Neutralizing Antibody)

86408

8/10/2020

Screening (Neutralizing Antibody)

86409

8/10/2020

Encounter for Screening COVID-19

Z11.52

1/1/2021

Contact with and (suspected) exposure to COVID-19

Z20.822

1/1/2021

VEKLURY Antiviral Medication

J0248

12/23/2021

Convalescent Plasma

C9507

12/28/2021

Multisystem inflammatory syndrome (MIS)

M35.81

1/1/2021

Treatment

U07.1

4/1/2020

Treatment

B97.29

1/27/2020-3/31/2020

AstraZeneca – Tixagev and Cilgav Injection

Q0220

12/8/2021

AstraZeneca – Tixagev and Cilgav Injection

M0220

12/8/2021

AstraZeneca – Tixagev and Cilgav Injection

M0221

12/8/2021

AstraZeneca – Tixagev and Cilgav Injection

Q0221

2/24/2022

Eli Lily – Bebtelovimab Injection

Q0222

2/11/2022

Eli Lily – Bebtelovimab Injection

M0222

2/11/2022

Eli Lily – Bebtelovimab Injection

M0223

2/11/2022

Eli Lily Monoclonal - Bamlan/Etesev Injection

Q0245

2/9/2021

Eli Lily Monoclonal - Bamlan/Etesev Infusion

M0245*

2/9/2021

Eli Lily Monoclonal - Bamlan/Etesev Infusion

M0246

5/6/2021

GSK Monoclonal - Sotrov Injection

Q0247

5/26/2021

GSK Monoclonal - Sotrov Infusion

M0247*

5/26/2021

GSK Monoclonal - Sotrov Infusion In Home

M0248

5/26/2021

Genentech Monoclonal - Tocili Injection

Q0249

6/24/2021

Genentech Monoclonal - Tocili 1st Infusion

M0249*

6/24/2021

Genentech Monoclonal - Tocili 2nd Infusion

M0250*

6/24/2021

Eli Lily Monoclonal - Bamlan Injection

Q0239

11/10/2020 - 5/6/21

Eli Lily Monoclonal - Bamlan Infusion

M0239*

11/10/2020 - 5/6/21

Regeneron Monoclonal - Casiri/Imdev Injection

Q0243

11/21/2020-1/23/22

Regeneron Monoclonal - Casiri/Imdev Infusion

M0243*

11/21/2020-1/23/22

Regeneron Monoclonal - Casiri/Imdev Injection

Q0244

6/3/2021-1/23/22

Regeneron Monoclonal - Casiri/Imdev Infusion

M0244

5/6/2021-1/23/22

Regeneron Monoclonal - Casiri/Imdev Injection

Q0240

7/30/2021-1/23/22

Regeneron Monoclonal - Casiri/Imdev Infusion

M0240

7/30/2021-1/23/22

Regeneron Monoclonal - Casiri/Imdev Infusion

M0241

7/30/2021-1/23/22

Home Vaccine Admin

M0201

6/8/2021

Pfizer Vaccine

91300

12/11/2020

Pfizer Vaccine Admin - 1st Dose

0001A

12/11/2020

Pfizer Vaccine Admin - 2nd Dose

0002A

12/11/2020

Pfizer Vaccine Admin - 3rd Dose

0003A

8/12/2021

Pfizer Vaccine Admin - Booster

0004A

9/22/2021

Moderna Vaccine

91301

12/18/2020

Moderna Vaccine Admin - 1st Dose

0011A

12/18/2020

Moderna Vaccine Admin - 2nd Dose

0012A

12/18/2020

Moderna Vaccine Admin - 3rd Dose

0013A

8/12/2021

Moderna Vaccine (Low Dose)

91306

10/20/2021

Moderna Vaccine (Low Dose) - Booster

0064A

10/20/2021

Janssen Vaccine

91303

2/27/2021

Janssen Vaccine Admin - Single Dose

0031A

2/27/2021

Janssen Vaccine Admin – Booster

0034A

10/20/21 

Pfizer Vaccine (Pediatric)

91307

10/29/2021

Pfizer Vaccine (Pediatric) Admin - 1st Dose

0071A

10/29/2021

Pfizer Vaccine (Pediatric) Admin - 2nd Dose

0072A

10/29/2021

Pfizer SARS-COV2 Vaccine, mRNA-LNP 10MCG/0.2mL for 5 - 11 years - Booster

0074A

5/17/2022

Pfizer Vaccine (Ready to use)

91305

1/3/2022

Pfizer Vaccine (Ready to use) Admin - 1st Dose

0051A

1/3/2022

Pfizer Vaccine (Ready to use) Admin - 2nd Dose

0052A

1/3/2022

Pfizer Vaccine (Ready to use) Admin - 3rd Dose

0053A

1/3/2022

Pfizer Vaccine (Ready to use) Admin – Booster

0054A

1/3/2022

Moderna COVID-19 Vaccine 50MCG/0.5ML – Booster Administration

0094A

3/7/2022

Moderna SARS-COV2 Vaccine, mRNA-LNP 50MCG/0.5mL 6 years – 11 years

91309

3/7/2022

Pfizer -SARS-COV2 Vaccine, mRNA-LNP 3MCG/0.2mL for 6 months – 5 years – 1st Dose  Administration

0081A

2/2/2022

Pfizer - SARS-COV2 Vaccine, mRNA-LNP 3MCG/0.2mL for 6 months – 5 years – 2nd Dose Administration

0082A

2/1/2022

Pfizer -SARS-COV2 Vaccine, mRNA-LNP 3MCG/0.2mL for 6 months – 5 years

91308

2/1/2022

NEW - Moderna Covid-19 Pediatric Vaccine 6 months - 5 years 250MCG/0.25ML

91311

7/1/2022

NEW - Moderna Covid-19 Pediatric Vaccine 6 months - 5 years Administration – 1st dose

0111A

7/1/2022

NEW - Moderna Covid-19 Pediatric Vaccine 6 months - 5 years Administration – 2nd dose

0112A

7/1/2022

 

 

Code Type

Code

Effective*

Testing (CDC)

U0001

2/4/2020

Testing (Non-CDC)

U0002

2/4/2020

Testing (Industry Standard)

87635

3/13/2020

Testing (Infectious Disease)

0202U

5/20/2020

Testing (Throughput)

U0003

4/14/2020

Testing (Throughput)

U0004

4/14/2020

Testing (Antigen)

0223U

6/25/2020

Testing (Antigen)

0224U

6/25/2020

Testing (Infectious Disease)

0225U

8/10/2020

Testing (sVNT)

0226U

8/10/2020

Testing

86413

9/8/2020

Testing (Infectious Disease)

0240U

10/6/2020

Testing (Infectious Disease)

0241U

10/6/2020

Testing (Infectious Agent Detection)

87636

10/6/2020

Testing (Infectious Agent Detection)

87637

10/6/2020

Testing (Infectious Agent Detection)

87811

10/6/2020

Mutation identification SARS CoV-2

87913

2/21/2022

Testing (Add-On Payment)

U0005

1/1/2021

OTC At Home COVID Tests

N/A

1/15/2022

Screening

Z03.818

2/4/2020

Screening (Specimen Transfer)

G2023

3/1/2020

Screening (Specimen Transfer)

G2024

3/1/2020

Screening (Specimen Transfer)

C9803

3/1/2020

Screening (Antibody Testing)

86328

4/10/2020

Screening (Antibody Testing)

86769

4/10/2020

Screening (Antigen Detection)

87426

6/25/2020

Screening (Antigen Detection)

87428

11/10/2020

Screening (Neutralizing Antibody)

86408

8/10/2020

Screening (Neutralizing Antibody)

86409

8/10/2020

Encounter for Screening COVID-19

Z11.52

1/1/2021

Contact with and (suspected) exposure to COVID-19

Z20.822

1/1/2021

VEKLURY Antiviral Medication

J0248

12/23/2021

Convalescent Plasma

C9507

12/28/2021

Multisystem inflammatory syndrome (MIS)

M35.81

1/1/2021

Treatment

U07.1

4/1/2020

Treatment

B97.29

1/27/2020-3/31/2020

AstraZeneca – Tixagev and Cilgav Injection

Q0220

12/8/2021

AstraZeneca – Tixagev and Cilgav Injection

M0220

12/8/2021

AstraZeneca – Tixagev and Cilgav Injection

M0221

12/8/2021

AstraZeneca – Tixagev and Cilgav Injection

Q0221

2/24/2022

Eli Lily – Bebtelovimab Injection

Q0222

2/11/2022

Eli Lily – Bebtelovimab Injection

M0222

2/11/2022

Eli Lily – Bebtelovimab Injection

M0223

2/11/2022

Eli Lily Monoclonal - Bamlan/Etesev Injection

Q0245

2/9/2021

Eli Lily Monoclonal - Bamlan/Etesev Infusion

M0245*

2/9/2021

Eli Lily Monoclonal - Bamlan/Etesev Infusion

M0246

5/6/2021

GSK Monoclonal - Sotrov Injection

Q0247

5/26/2021

GSK Monoclonal - Sotrov Infusion

M0247*

5/26/2021

GSK Monoclonal - Sotrov Infusion In Home

M0248

5/26/2021

Genentech Monoclonal - Tocili Injection

Q0249

6/24/2021

Genentech Monoclonal - Tocili 1st Infusion

M0249*

6/24/2021

Genentech Monoclonal - Tocili 2nd Infusion

M0250*

6/24/2021

Eli Lily Monoclonal - Bamlan Injection

Q0239

11/10/2020 - 5/6/21

Eli Lily Monoclonal - Bamlan Infusion

M0239*

11/10/2020 - 5/6/21

Regeneron Monoclonal - Casiri/Imdev Injection

Q0243

11/21/2020-1/23/22

Regeneron Monoclonal - Casiri/Imdev Infusion

M0243*

11/21/2020-1/23/22

Regeneron Monoclonal - Casiri/Imdev Injection

Q0244

6/3/2021-1/23/22

Regeneron Monoclonal - Casiri/Imdev Infusion

M0244

5/6/2021-1/23/22

Regeneron Monoclonal - Casiri/Imdev Injection

Q0240

7/30/2021-1/23/22

Regeneron Monoclonal - Casiri/Imdev Infusion

M0240

7/30/2021-1/23/22

Regeneron Monoclonal - Casiri/Imdev Infusion

M0241

7/30/2021-1/23/22

Home Vaccine Admin

M0201

6/8/2021

Pfizer Vaccine

91300

12/11/2020

Pfizer Vaccine Admin - 1st Dose

0001A

12/11/2020

Pfizer Vaccine Admin - 2nd Dose

0002A

12/11/2020

Pfizer Vaccine Admin - 3rd Dose

0003A

8/12/2021

Pfizer Vaccine Admin - Booster

0004A

9/22/2021

Moderna Vaccine

91301

12/18/2020

Moderna Vaccine Admin - 1st Dose

0011A

12/18/2020

Moderna Vaccine Admin - 2nd Dose

0012A

12/18/2020

Moderna Vaccine Admin - 3rd Dose

0013A

8/12/2021

Moderna Vaccine (Low Dose)

91306

10/20/2021

Moderna Vaccine (Low Dose) - Booster

0064A

10/20/2021

Janssen Vaccine

91303

2/27/2021

Janssen Vaccine Admin - Single Dose

0031A

2/27/2021

Janssen Vaccine Admin – Booster

0034A

10/20/21 

Pfizer Vaccine (Pediatric)

91307

10/29/2021

Pfizer Vaccine (Pediatric) Admin - 1st Dose

0071A

10/29/2021

Pfizer Vaccine (Pediatric) Admin - 2nd Dose

0072A

10/29/2021

Pfizer SARS-COV2 Vaccine, mRNA-LNP 10MCG/0.2mL for 5 - 11 years - Booster

0074A

5/17/2022

Pfizer Vaccine (Ready to use)

91305

1/3/2022

Pfizer Vaccine (Ready to use) Admin - 1st Dose

0051A

1/3/2022

Pfizer Vaccine (Ready to use) Admin - 2nd Dose

0052A

1/3/2022

Pfizer Vaccine (Ready to use) Admin - 3rd Dose

0053A

1/3/2022

Pfizer Vaccine (Ready to use) Admin – Booster

0054A

1/3/2022

Moderna COVID-19 Vaccine 50MCG/0.5ML – Booster Administration

0094A

3/7/2022

Moderna SARS-COV2 Vaccine, mRNA-LNP 50MCG/0.5mL 6 years – 11 years

91309

3/7/2022

Pfizer -SARS-COV2 Vaccine, mRNA-LNP 3MCG/0.2mL for 6 months – 5 years – 1st Dose  Administration

0081A

2/2/2022

Pfizer - SARS-COV2 Vaccine, mRNA-LNP 3MCG/0.2mL for 6 months – 5 years – 2nd Dose Administration

0082A

2/1/2022

Pfizer -SARS-COV2 Vaccine, mRNA-LNP 3MCG/0.2mL for 6 months – 5 years

91308

2/1/2022

NEW - Moderna Covid-19 Pediatric Vaccine 6 months - 5 years 250MCG/0.25ML

91311

7/1/2022

NEW - Moderna Covid-19 Pediatric Vaccine 6 months - 5 years Administration – 1st dose

0111A

7/1/2022

NEW - Moderna Covid-19 Pediatric Vaccine 6 months - 5 years Administration – 2nd dose

0112A

7/1/2022

TestingU00012/4/2020TestingU00022/4/2020Testing876353/13/2020Testing0202U5/20/2020Testing/ThroughputU00034/14/2020Testing/ThroughputU00044/14/2020Testing/Antigen0223U6/25/2020Testing/Antigen0224U6/25/2020Testing0225U8/10/2020Testing0226U8/10/2020Testing864139/8/2020Testing0240U10/6/2020Testing0241U10/6/2020Testing8763610/6/2020Testing8763710/6/2020Testing8781110/6/2020TestingU00051/1/2021ScreeningZ20.8282/4/2020ScreeningZ03.8182/4/2020Screening/ Specimen Transfer G20233/1/2020Screening/ Specimen TransferG20243/1/2020Screening/AntibodyC98033/1/2020Screening/Antibody863284/10/2020Screening/Antibody867694/10/2020Screening/Antigen874266/25/2020Screening/Neutralizing Antibody 864088/10/2020Screening/Neutralizing Antibody864098/10/2020Screening/Antigen8742811/10/2020ScreeningZ11.5201/01/2021ScreeningZ20.82201/01/2021TreatmentU07.14/1/2020TreatmentB97.291/27/2020 – 3/31/2020TreatmentM35.8101/01/2021Monoclonal Infusion*Q0239*11/9/2020 – 5/6/2021Monoclonal Infusion*M0239*11/9/2020 – 5/6/2021 Monoclonal Infusion (Regeneron)Q024311/21/2020 – 1/23/2022Monoclonal Infusion (Regeneron)M02445/6/2021 – 1/23/2022Monoclonal Infusion (Eli Lily)Q02452/9/2021 – 1/23/2022Treatment - Tixagev and cilgav, inj (AstraZeneca)M022012/8/2021Treatment - Tixagev and cilgav, hm (AstraZeneca)M022112/8/2021Monoclonal Infusion (Eli Lily)M0245*2/9/2021 – 1/23/2022Monoclonal Infusion (Eli Lily)M02465/6/2021 – 1/23/2022Treatment - Tixagev and cilgav, 300 mg (AstraZeneca)Q022012/8/2021Monoclonal Infusion (Regeneron)Q02446/3/2021 – 1/23/2022Monoclonal Infusion (GSK)Q02475/26/2021Monoclonal Infusion (GSK)M0247*5/26/2021Monoclonal Infusion (GSK)M02485/26/2021Monoclonal Antibody Treatment -(Regeneron)M024311/21/2020 – 1/23/2022Vaccine Treatment (Pfizer)9130012/11/2020 Vaccine Treatment (Pfizer)0001A12/11/2020Vaccine Treatment (Pfizer)0002A12/11/2020Vaccine Treatment (Pfizer)0003A8/12/2021Vaccine Booster Admin (Pfizer)0004A09/22/2021Pfizer (5-11): Vaccine Product9130711/03/2021Pfizer (5-11): Admin Code, First Dose0071A11/03/2021Pfizer (5-11): Admin Code, Second Dose0072A11/03/2021 *NEW* Pfizer Vaccine (Pediatric) Admin – 3rd Dose0073A1/3/2022*NEW* Pfizer Vaccine (Ready to use)913051/3/2022*NEW* Pfizer Vaccine (Ready to use) Admin - 1st Dose0051A1/3/2022*NEW* Pfizer Vaccine (Ready to use) Admin - 2nd Dose0052A1/3/2022*NEW* Pfizer Vaccine (Ready to use) Admin - 3rd Dose0053A1/3/2022*NEW* Pfizer Vaccine (Ready to use) Admin – Booster0054A1/3/2022 Vaccine Treatment (Moderna)9130112/18/2020Vaccine Treatment (Moderna)0011A12/18/2020Vaccine Treatment (Moderna)0012A12/18/2020Vaccine Treatment (Moderna)0013A8/12/2021Low Dose Vaccine (Moderna)9130610/20/2021Vaccine Booster Admin0064A10/20/2021Vaccine Treatment (Janssen)913032/27/2021Vaccine Treatment (Janssen)0031A2/27/2021Vaccine Booster Admin (Janssen)0034A10/20/2021In Home Vaccine Admin Add-On CodeM02016/8/2021*NEW* VEKLURY Antiviral MedicationJ024812/23/21*NEW* Convalescent PlasmaC950712/28/21 [MM1]  

 

*On April 16, 2021, the FDA revoked the EUA that allowed for the investigational monoclonal antibody therapy bamlanivimab, when administered alone, to be used for the treatment of mild-to-moderate COVID-19 in adults and certain pediatric patients. Due to this revocation, the Medicaid and Medicare programs will not pay for claims with HCPCS codes M0239 or Q0239 with dates of service after 4/16/2021.

 


 [MM1]HOLD Per COVID Small Group

Provider Access Online

Verify member eligibility/renewal, check claims status, and more.

Manuals and Forms

Provider manuals, tip sheets, important forms, and applications. 

Authorization Grids

Authorization Grids for Medicare, Medicaid, Child Health Plus, and NY State of Health Marketplace plans.