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 57 Results
Title Last Updated
Acthar Gel® (Repository Corticotropin Injection) - for Infantile Spasms, Multiple Sclerosis Exacerbations Open a PDF 5/6/2021
Aduhelm (aducanumab-avwa) Policy Open a PDF 9/1/2021
Alpha-1 Antitrypsin Therapy (AAT) Open a PDF 9/1/2021
Anorexiants; Contrave (naltrexone/bupropion ER), QsymiaTM (phentermine/topiramate ER), Saxenda (liraglutide), Wegovy (semaglutide) and Xenical® (orlistat), Imcivree (setmelanotide) Open a PDF 9/15/2021
Antihemophilic Agents Open a PDF 5/10/2021
Attention Deficit Hyperactivity Disorder (ADHD) Stimulants Policy Open a PDF 9/1/2021
Blood Modifiers Open a PDF 8/31/2021
Botulinum Toxin (Botox, Dysport, Myobloc, Xeomin) – For Medicaid Managed Care Essential Plan and Child Health Plus Open a PDF 9/16/2021
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 (Certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis and Rheumatoid Arthritis Open a PDF 9/16/2021
Clinical Review Prior Authorization (CRPA) Medical Drugs Open a PDF 8/27/2021
Clinical Review Prior Authorization Rx (CRPA) Open a PDF 10/14/2021
Compounded Drug Products Open a PDF 2/11/2021
Coronavirus (COVID-19) Impacted Drug Therapies (azithromycin, chloroquine, hydroxychloroquine, ivermectin, Kaletra, lopinavir/ritonavir, Plaquenil, Stromectol, Zithromax) Open a PDF 9/28/2021
Duchenne Muscular Dystrophy (DMD): Amondys 45 (casimersen), Emflaza (deflazacort), Exondys 51 (eteplirsen), Viltepso (vilotarsen) and Vyondys 53 (golodirsen) Open a PDF 9/16/2021
Enbrel (etanercept) – for Ankylosing Spondylitis, Juvenile Idiopathic Arthritis, Plaque Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis Open a PDF 9/16/2021
Generic Advantage Program / MAC Penalty Open a PDF 6/8/2021
Growth Hormone Open a PDF 2/11/2021
Headache Disorders Open a PDF 10/14/2021
Hemlibra Open a PDF 5/6/2021
Hereditary Angioedema (HAE) Open a PDF 3/9/2021
Humira ® (adalimumab) – for Psoriasis, Rheumatoid Arthritis, Juvenile Idiopathic Arthritis, Psoriatic Arthritis, Ankylosing Spondylitis, Hidradenitis Suppurativa, Crohn’s Disease, Ulcerative Colitis and Panuveitis Open a PDF 9/16/2021
Immune Checkpoint Inhibitor Clinical Review Prior Authorization (CRPA) (Bavencio, Imfinzi, Jemperli, Keytruda, Libtayo, Opdivo, Tecentriq, Yervoy) Open a PDF 10/15/2021
Inborn Errors of Metabolic Diseases (IEM) Open a PDF 10/13/2021
Infertility Medications Open a PDF 9/16/2021
Showing 1– 25 of 57 Results

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