Prescription Drug Policies

The following is a list of our prescription drug policies. If you cannot find a policy for a specific medication, please select the link titled 'Clinical Review Prior Authorization' from the list below.

As of April 1, 2023, members enrolled in Blue Choice Option, HMO Blue Option, and Blue Option Plus receive their prescription medications through NYRx, the Medicaid Pharmacy Program.

Learn more about the transition of the pharmacy benefit from Blue Choice Option, HMO Blue Option, and Blue Option Plus to NYRx, the Medicaid Pharmacy Program.

Access general information about NYRx, the Medicaid Pharmacy Program, along with additional information for Members and Providers.

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Showing 1– 50 of 85 Results
Title Last Updated
Xolair (omalizumab) Drug Policy Open a PDF 06/01/2026
Xiaflex - Medical Benefit (collagenase clostridium histolyticum) Policy Open a PDF 06/01/2026
Weight Related Comorbidities for Overweight, Obesity, Noncirrhotic Metabolic Dysfunction - Associated Steatohepatitis (MASH) & Cardiovascular Disease (Contrave, Foundayo, Liraglutide, Orlistat, Qsymia, phentermine-topiramate ER, Saxenda, Wegovy, Xenical, & Zepbound) (Self-Administration) - Rx Benefit (New Start and Recertification) Open a PDF 06/24/2026
Viscosupplementation with Hyaluronic Acid (Durolane, Euflexxa, Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Hymovis One, Monovisc, Orthovisc, Supartz, Synojoynt, Synvisc One, Triluron, TriVisc, Visco-3) (Health Professional Administered) – Medical Benefit Open a PDF 06/01/2026
Ustekinumab Drug Policy (Imuldosa [ustekinumab-srlf], Otulfi [ustekinumab-aauz], Pyzchiva [ustekinumab-ttwe], Pyzchiva [ustekinumab-ttwe][Cordavis]], (Selarsdi [ustekinumab-aekn], Stelara [ustekinumab], Steqeyma [ustekinumab-stba], ustekinumab [Janssen Biotech], ustekinumab-aekn, ustekinumab-ttwe [Quallent], Wezlana [ustekinumab-auub][Optum-Nuvalia]], Yesintek [ustekinumab-kfce]) (Self-Administered & Health Professional Administered) – Rx Benefit & Medical Benefit Open a PDF 06/01/2026
Tezspire™ (tezepelumab-ekko subcutaneous injection) Open a PDF 06/01/2026
Testosterone Drug Policy (Testopel, Aveed, & Azmiro) (Health Professional Administered) - Medical Benefit Open a PDF 06/01/2026
Systemic Lupus Erythematosus (SLE) and Lupus Nephritis (LN): Benlysta IV (benlimumab), Gazyva (obintuzumab), Lupkynis (voclosporin), and Saphnelo (anifrolumab-fnia) Drug Policy Open a PDF 06/01/2026
Step Therapy Drug Policy Open a PDF 06/04/2026
Spravato® (esketamine) Nasal Spray Drug Policy Open a PDF 05/29/2026
Spinal Muscular Atrophy (SMA) - Medical Benefit (Evrysdi (risdiplam), Spinraza (nusinersen), Zolgensma (onasemnogene abeparovec-xioi)) Open a PDF 06/12/2026
Site of Care Redirection for Medical Specialty Drug Administration Policy Open a PDF 06/01/2026
Sickle Cell Disease Management - Adakveo (crizanlizumab-tmca (Medical)), Endari (L-glutamine oral powder (Rx)), Oxbryta (voxelotor (Rx) for 300 mg Tablets, 500mg Tablets and 300mg Tablets for Oral Suspension, Siklos (hydroxyurea tablets (Rx), Xromi (Rx)) Open a PDF 06/01/2026
Ryoncil (remestemcel-l-rknd) Drug Policy - (Health Professional Administered) - Medical Benefit Open a PDF 06/12/2026
Rezdiffra (resmetirom) Drug Policy (Self Administration) - Rx Benefit Open a PDF 05/14/2026
Respiratory Syncytial Virus (RSV) Prophylaxis (Synagis (palivizumab), Beyfortus (nirsevimab) and Enflonsia (clesrovimab)) (Health Professional Administered) - Medical Benefit Open a PDF 06/01/2026
Repository Corticotropin Injection (Medical & Rx Benefit) (Acthar HP and Purified Cortrophin gel) - for Infantile Spasms, Multiple Sclerosis Exacerbations Open a PDF 06/01/2026
Remicade® (infliximab), Infliximab, Renflexis® (infliximab-abda), Avsola® (infliximab-axxq), Inflectra® (infliximab-dyyb) - (Health Professional Administered) - Medical Benefit Open a PDF 06/01/2026
Rare Diseases CRPA Policy (Actimmune (Medical & Rx), Adzynma (Medical), Aldurazyme (Medical), Aqvesme (Rx), Arcalyst (Rx), Bkemv (Medical), Bylvay (Rx), Camzyos (Rx), Crenessity (Rx), Cuprimine and generic penicillamine capsules (Rx), Cuvrior (Rx), Daybue (Rx), Empaveli (Rx), Enjaymo (Medical), Enspryng (Rx or Medical), Epysqli (Medical), Evkeeza (Medical), Fabhalta (Rx), Filspari (Rx), Firdapse (Rx), Galzin (Rx), Gamifant (Medical), Hyftor 0.2% gel (Rx), Ilaris (Medical), Imcivree (Rx), Increlex (Rx), Isturisa (Rx), Joenja (Rx), Juxtapid (Rx), Keveyis (Rx), Korlym (Rx), Livmarli (Rx), Luxturna (Medical), Myalept (Rx), Mycapssa (Rx), Ormalvi (Rx), Piasky (Medical), Procysbi (Rx), Pyrukynd (Rx), Reblozyl (Medical), Recombinant (Rx), Recorlev (Rx), Redemplo (Rx), Rethymic (Medical), Revcovi - (Medical & Rx), rh-IGF-1 (Rx), Ryplazim (Medical & Rx), Rystiggo (Medical), Sandostatin LAR and octreotide intramuscular injection (Rx & Medical), Scenesse (Medical), Signifor LAR (Medical), Signifor SC (Rx), Skyclarys (Rx), Skysona (Medical), Sohonos (Rx), Soliris 2mg & 10mg (Medical), Somavert (Rx), Sylvant (Medical), Syprine, generic trientine capsules (Rx), Tarpeyo (Rx), Tavneos (Rx), Tepezza (Medical), Thiola, Thiola EC, and generic tiopronin (Rx), Tryngolza (Rx), Tzield (Medical), Ultomiris (Medical), Uplizna (Medical), Vanrafia, (Rx), Venxxiva (Rx), Veopoz (Medical), Vijoice (Rx), Voxzogo (Rx), Voydeya (Rx), Vyjuvek (Medica & Rxl), Vyvgart (Medical), Vyvgart Hytrulo (Medical), Xolremdi (Rx), Yorvipath (Rx), Zevaskyn (Medical), Zilbrysq (Rx), Zokinvy (Rx), Ztalmy (Rx), Zynteglo (Rx)) (Health Professional Administered) - Medical Benefit OR (Self-Administered) - Rx Benefit Open a PDF 06/12/2026
Quantity Limit Open a PDF 11/13/2025
Qalsody (tofersen) Drug Policy (Health Professional Administered) - Medical Benefit Open a PDF 06/01/2026
Pulmonary Hypertension (PH) Drug Policy - Adcirca (tadalafil (including Alyq)(Rx)), Adempas (riociguat (Rx)), epoprostenol (Medical)), Flolan, Letairis (ambrisentan (Rx)), Liqrev, Opsumit (macitentan (Rx)), Opsynvi (macitentan & tadalafil (Rx)), Orenitram (treprostinil (Rx)), Remodulin (treprostinil (Medical)), Revatio (sildenafil (Rx)), Tadliq (Rx)), Tracleer (bosentan (Rx)), Tyvaso (treprostinil) inhalation (Rx), Tyvaso DPI (Rx)), Uptravi (selexipag) Rx)), Veletri (Medical), Ventavis (iloprost) inhalation (Medical)), Winrevair (sotatercept) (Rx & Medical)), & Combination Therapy (Ambrisentan and tadalafil) Open a PDF 05/14/2026
Patient Protection and Affordable Care Act (PPACA) - Preventive Items and Services Open a PDF 02/12/2026
Parkinson’s Disease Drug Policy – (Self Administration) - Rx Benefit OR (Health Professional Administered) - Medical Benefit - (Apokyn & apomorphine hydrochloride injection (Rx), Gocovri - amantadine ER capsules (Rx), Inbrija - levodopa inhalation (Rx), Mirapex ER and pramipexole ER (Rx), Neupro - rotigotine patch (Rx), Nourianz - istradefylline tablets (Rx), Nuplazid - pimavanserin tablets & capsules (Rx), Onapgo (apomorphine) (Rx & Medical), Osmolex - amantadine ER tablet (Rx), Rytary and Crexont - carbidopa/levodopa ER capsule (Rx), Vyalev (foscarbidopa/foslevodopa injection) (Rx & Medical), Xadago (safinamide mesylate), Zelapar ODT - Selegiline Hydrochloride (L-Deprenyl) tablet (Rx) Open a PDF 05/14/2026
Papzimeos™ (zopapogene imadenovec-drba) Drug Policy Open a PDF 06/12/2026
Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp) Open a PDF 05/14/2025
Osteoporosis Drug Policy – (Bildyos, Bonsity, Bosaya, calcitonin salmon injection, Conexxence, Evenity®, Forteo®, Jubbonti, Miacalcin injection®, Ospomyv, Prolia®, Stoboclo (denosumab-bmwo), Teriparatide, Tymlos®) Rx Benefit (Self-Administered) & Medical Benefit (Health Professional Administered) Open a PDF 06/01/2026
Opioid Management Health and Safety Program - (Concurrent use of Opioid/Buprenorphine Products, Extended-release (long-acting) opioids, Morphine Milligram Equivalents (MME), Levorphanol, Opioid-naïve ADULT 7-day supply for first FOUR fills limit, Opioid-naïve PEDIATRIC 3-day supply for first FOUR fills limit, Opioid Cough & Cold medicines, Opioids drugs requiring Step Therapy, Prolate Solution & Generic oxycodone-APAP 100-300mg/5ml, Prolate tablets, Nalocet, & generic oxycodone-APAP 5mg/300mg and oxycodone-APAP 10mg/300mg & oxycodone-APAP 2.5mg/300mg, and Roxybond Open a PDF 05/14/2026
Ophthalmic Vascular Endothelial Growth Factor (VEGF) Inhibitors (Beovu, Byooviz, Cimerli, Eylea, Eylea HD, Lucentis, Pavblu, Susvimo, Vabysmo) (Health Professional Administered) – Medical Benefit Open a PDF 06/01/2026
Oncology Clinical Review Prior Authorization (CRPA) Rx Drug (Abiraterone 500 mg tablet, Afinitor, Afinitor Disperz, Akeega, Alecensa, Alunbrig, Augtyro, Avmapki Fakzynja co-pack, Ayvakit, Balversa, Besremi, (both Rx and Medical benefit drug), Bexarotene Capsules, Bosulif, Braftovi, Brukinsa, Cabometyx, Calquence, Caprelsa, Cometriq, Copiktra, Cotellic, Danziten, Dasatinib, Daurismo, Ensacove, Erivedge, Erleada, Erlotinib, Everolimus tablets or suspension), Fotivda, Fruzaqla, Gavreto, Gefitinib, Gilotrif, Gomekli, Hemady, Hernexeos, Ibrance, Ibtrozi, Iclusig, Idhifa, Imbruvica (tablets or suspension), Imkeldi suspension, Inqovi, Inluriyo, Inlyta, Inrebic, Iressa, Itovebi, Iwilfin, Jakafi, Jaypirca, Kisqali, Komzifti, Koselugo, Krazati, Lapatinib, Lazcluze, Lenvima, Lifyorli, Lonsurf, Lorbrena, Lumakras, Lynparza tablets, Lytgobi, Mekinist, Mektovi, Mercaptopurine oral suspension, Modeyso, Nerlynx, Nexavar, Nilotinib, Nilotinib d-tartrate, Ninlaro, Nubeqa, Odomzo, Ogsiveo, Ojemda, Ojjaara, Onureg, Orgovyx, Orserdu, Pazopanib, Pemazyre, Phyrago, Piqray, Pomalidomide, Pomalyst, Purixan, Qinlock, Retevmo, Revuforj, Rezlidhia Rezurock, Romvimza, Rozlytrek, Rubraca, Rydapt, Scemblix, Soltamox, Sorafenib, Sprycel, Stivarga, Sutent, Tabrecta, Tafinlar, Tagrisso, Talzenna, Tarceva, Targretin capsules, Targretin gel, Tasigna, Tazverik, Tepmetko, Tibsovo, Torpenz, Truqap, Tukysa, Turalio, Tykerb, Valchlor, Vanflyta, Venclexta, Verzenio, Vitrakvi, Vizimpro, Vonjo, Voranigo, Votrient, Welireg, Xalkori, Xermelo, Xospata, Xpovio Xtandi, Yonsa, Zejula, Zelboraf, Zolinza, Zydelig, Zykadia, Zytiga) (Self-Administration) - Rx Benefit Open a PDF 05/22/2026
Oncology Clinical Review Prior Authorization (CRPA) Medical Drug Policy (Abraxane, Adcetris, Adstiladrin, Amtagvi, Anktiva, Arzerra, Asparlas, Aukelso, Avgemsi, Axtle, Beizray, Beleodaq, Belrapzo, Bendamustine HCL, Bendeka, Besponsa, Bilprevda, Bispecific T-Cell Engagers (BiTE), Bizengri, Blenrep, Blincyto, Bomyntra, Boruzu, Camcevi, Cinvanti, Colimvi, Cyramza, Danyelza, Darzalex, Darzalex Faspro, Datroway, Docivyx, Elahere, Elitek, Elrexfio, Elzonris, Empliciti, Emrelis, Enhertu, Epkinly, Erwinaze, Focinvez, Folotyn, Fosaprepitant, Fyarro, Gazyva, Hepzato Kit, Imdelltra, Infugem, Inlexzo, Istodax, Ivra, Jelmyto, Kadcyla, Kimmtrak, Kyprolis, Kyxata, Lartruvo, Leuprolide Acetate Depot, Lumoxiti, Lunsumio, Lutrate Depot, Lymphir, Lynozyfic, Margenza, Monjuvi, Mylotarg, Niktimvo, Oncaspar, Onivyde, Osenvelt, Paclitaxel protein-bound particles, Padcev, Pedmark, Pemfexy, Pemrydi, Phesgo, Polivy, Portrazza, Posfrea, Poteligeo, Pralatrexate, Provenge, Romidepsin, Rybrevant, Rybrevant Faspro, Rylaze, Rytelo, Sarclisa, Talvey, Tecelra, Tecvayli, Temsirolimus, Tepylute, Tivdak, Torisel, Treanda, Trodelvy, Vectibix, Vivimusta, Vyloy, Vyxeos, Wyost, Xgeva, Xtrenbo, Yondelis, Zaltrap, Zepzelca, Ziihera, Zusduri, & Zynlonta) (Health Professional Administered) - Medical Benefit Open a PDF 06/26/2026
Oncology Biosimilar Drug Policy - (Avastin (bevacizumab) and Alymsys (bevacizumab-maly), Herceptin (trastuzumab), Herceptin Hylecta (trastuzumab and hyaluronidase-oysk), Hercessi (trastuzumab-strf), Jobevne (bevacizumab-mwgd) Ogivri (trastuzumab-dkst), Ontruzant (trastuzumab-dttb), and Herzuma (trastuzumab-pkrb), Rituxan (rituximab), Rituxan Hycela (rituximab hyaluronidase), Riabni (rituximab-arrx) and Vegzelma (bevacizumab-adcd)) – Medical Benefit Open a PDF 06/01/2026
Omisirge (omidubicel-onlv) (Health Professional Administered) - Medical Benefit Open a PDF 06/12/2026
Ohtuvayre (ensifentrine) Policy for Commercial, Exchange, & SafetyNet - Rx Benefit; Medicare Advantage & DSNP - Medical Benefit Open a PDF 06/01/2026
Off-Label Use of FDA Approved Drugs Open a PDF 06/01/2026
Non-Formulary Medication Exception Review Policy Open a PDF 06/01/2026
Monoclonal Antibodies for the Treatment of Hemophilia – (Health Professional Administered) Medical Benefit & (Self-Administered) Rx Benefit - (Alhemo, Hemlibra, Hympavzi, Qfitlia) Open a PDF 06/17/2026
Medicare Part D Formulary Level Cumulative Opioid and Opioid / Buprenorphine POS Edits Open a PDF 03/11/2025
Medicare Part D 2026 Step Therapy Policy Open a PDF 06/01/2026
Medicare Part D 2026 Prior Authorization Policy Open a PDF 06/01/2026
Medicare Part B Step Therapy Drug List Open a PDF 06/08/2026
Lyfgenia (lovotibeglogene autotemcel) Drug Policy (Health Professional Administered) - Medical Benefit Open a PDF 06/12/2026
Low Clinical Impact for Rx Drugs Policy Open a PDF 06/12/2026
Lantidra (donislecel-jujn) Drug Policy for Commercial, Essential Plan, Medicaid Managed Care & Medicare (Health Professional Administered) - Medical Benefit Open a PDF 06/12/2026
Kebilidi (eladocagene exuparvovec-tneq) (Health Professional Administered) - Medical Benefit Open a PDF 06/01/2026
Intravenous Iron Replacement Products Drug Policy (Injectafer (ferric carboxymaltose) (Health Professional Administered) – Medical Benefit Open a PDF 06/01/2026
Intravenous Immune Globulin (IVIG) & Sub-Cutaneous Immune Globulin (SCIG) Therapy (Alyglo, Asceniv, Bivigam, Cutaquig, Cuvitru, Flebogamma, Gammagard Liquid, Gammagard S/D powder, Gammaked, Gammaplex, Gamunex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, Xembify) (Self-Administered) – Rx Benefit & (Health Professional Administered) - Medical Benefit Open a PDF 06/01/2026
Interleukin Antagonists for Asthma and Other Conditions - (Health Professional Administered) Medical Benefit & (Self-Administered) Rx Benefit - (Adbry, Bullous Pemphigoid, Cinqair, Dupixent, Ebglyss, Exdensur, Fasenra, Icotyde, Nemluvio, & Nucala) Open a PDF 06/04/2026
Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs - (Actemra (Medical or Rx), Bimzelx, Cibinqo - abrocitinib (Rx), Cosentyx - secukinumab (Rx), Ilumya – tildrakizumab-asmn (Medical), Kevzara – sarilumab (Rx), Kineret - anakinra (Rx), Olumiant – baricitinib (Rx), Orencia - abatacept (Medical or Rx), Otezla - apremilast (Rx), Rhapsido (Rx), Rinvoq – upadacitinib (Rx), Siliq – brodalumab (Rx), Skyrizi – risankizumab-rzaa (Rx), Simponi - golimumab (Medical or Rx), Sotyktu (deucravacitinib) (Rx), Spevigo (spesolimab-sbzo) (Rx), Taltz – ixekizumab (Rx), Tremfya (Medical or Rx), Tofidence (Medical), Tyenne (Medical & Rx), Xeljanz and Xeljanz XR- tofacitinib and tofacitinib ER (Rx), Zeposia- ozanimod (Rx)) Open a PDF 06/23/2026
Infertility Medications (Cetrotide, Cetrorelix Acetate, chorionic gonadotropin (hCG), Endometrin, Follistim AQ, Fyremadel, Ganirelix, Gonal-F, Leuprolide, Menopur, Novarel, Ovidrel, Pregnyl) (Self Administration) - Rx Benefit Open a PDF 10/08/2025
Showing 1– 50 of 85 Results

 

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