Prescription Drug Polices

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.

*Pharmacy benefit drugs - Excellus BlueCross BlueShield continues to manage the pharmacy benefit for Medicaid Managed Care and Child Health Plus members. Use the Excellus Pharmacy Management Drug Policies below.

Showing 1– 25 of 55 Results
Title Last Updated
Acthar Open a PDF 05/16/2020
Alpha-1 Antitrypsin Therapy (AAT) Open a PDF 8/28/2020
Anorexiants Open a PDF 12/23/2020
Antihemophilic Agents Open a PDF 4/20/2020
Attention Deficit Hyperactivity Disorder (ADHD) Stimulants Policy Open a PDF 10/22/2020
Blood Modifiers Open a PDF 12/23/2020
Botulinum Toxin (Medical Policy) Open a PDF 10/22/2020
Chronic Hepatitis C (Pegasys, Peg-Intron, ribavirin, Sovaldi, Harvoni, ledipasvir/sofosbuvir, Zepatier, Epclusa, sofosbuvir/velpatasvir, Vosevi, Mavyret) for Commercial, NYSOH Individual Market, NYSOH Employer Group Market Products, and Managed Medicaid products (Vosevi only) Open a PDF 12/4/2020
Cimzia Open a PDF 1/1/2021
Clinical Review Prior Authorization (CRPA) Medical Drugs Open a PDF 10/26/2020
Clinical Review Prior Authorization Rx (CRPA) Open a PDF 1/5/2021
Compounded Drug Products Open a PDF 1/14/2021
Coronavirus (COVID-19) Impacted Drug Therapies (azithromycin, chloroquine, hydroxychloroquine, Kaletra, lopinavir/ritonavir, Plaquenil, Zithromax) Open a PDF 6/10/2020
Duchenne Muscular Dystrophy (DMD): (Exondys 51 (eteplirsen) and Vyondys 53 (golodirsen)) Open a PDF 9/03/2020
Enbrel Open a PDF 1/1/2021
Generic Advantage Program / MAC Penalty Open a PDF 7/8/2020
Growth Hormone Open a PDF 2/3/2020
Headache Disorders Open a PDF 12/8/2020
Hemlibra Open a PDF 10/01/2020
Hereditary Angioedema (HAE) Open a PDF 1/5/2021
Humira Open a PDF 10/05/2020
Immune Checkpoint Inhibitor Clinical Review Prior Authorization (CRPA) Open a PDF 12/28/2020
Inborn Errors of Metabolic Diseases (IEM) Open a PDF 1/12/2021
Infertility Open a PDF 11/1/2020
Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs PDF Open a PDF 1/1/2021
Showing 1– 25 of 55 Results

Make a Comment

We invite practitioners to review & comment on our policies.