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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We invite practitioners to review & comment on our policies.

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Showing 1– 50 of 85 Results
Title Last Updated
Quantity Limit Open a PDF 11/13/2025
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
Medicare Part B Step Therapy Drug List Open a PDF 07/07/2026
Ophthalmic Vascular Endothelial Growth Factor (VEGF) Inhibitors (Beovu, Byooviz, Cimerli, Eylea, Eylea HD, Lucentis, Nufymco, Pavblu, Susvimo, Vabysmo) (Health Professional Administered) – Medical Benefit Open a PDF 07/02/2026
Site of Care Redirection for Medical Specialty Drug Administration Policy Open a PDF 07/01/2026
Medicare Part D 2026 Step Therapy Policy Open a PDF 07/01/2026
Medicare Part D 2026 Prior Authorization Policy Open a PDF 07/01/2026
Dual Special Needs Plan (D-SNP) 2026 Prior Authorization Policy Open a PDF 07/01/2026
Dual Special Needs Plan (D-SNP) 2026 Step Therapy Policy Open a PDF 07/01/2026
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 07/01/2026
Hereditary Angioedema (HAE) for Andembry, Berinert, Cinryze, Dawnzera, Ekterly, Firazyr, Icatibant Haegarda, Kalbitor, Orladeyo, Ruconest, Sajazir, and Takhzyro (Self-Administered & Health Professional Administered) – Rx Benefit & Medical Benefit Open a PDF 07/01/2026
Clinical Review Prior Authorization (CRPA) Medical Drug Policy for Medicaid Managed Care, HARP, Essential Plan & Dual Special Needs Plan (Benlysta IV, Briumvi, Cablivi (Rx & Medical), Ceprotin, Fensolvi, Gazyva, Gonadotropin-releasing hormone (GnRH) Analogs, Hydroxyprogesterone Caproate Injection, Krystexxa, Lemtrada, Leqvio, Ocrevus, Ocrevus Zunovo , Pemgarda, Rebyota, Saphnelo, Spravato, Supprelin LA, Triptodur, Tyruko, Tysabri, Ycanth, Zilretta, & Zoladex) (Self-Administered) OR (Health Professional Administered) – Medical Benefit Open a PDF 07/01/2026
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
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 06/26/2026
Low Clinical Impact for Rx Drugs Policy Open a PDF 06/26/2026
Cosmetic Medications Drug Policy (Latisse, Leqselvi, Litfulo, Mirvaso 0.33% gel, Multiple (e.g., Blanche), Opzelura cream, Pliaglis cream, Propecia, Refissa 0.05% cream, Renova 0.02% cream, Rhofade 1% cream, Tri-Luma Cream) – Rx Benefit & Medical Benefit Open a PDF 06/25/2026
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
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
Clinical Review Prior Authorization (CRPA) Rx Drug Policy Open a PDF 06/18/2026
Blood Modifiers - (Cosela, Filkri, Fulphila, Fylnetra, Granix, Neupogen, Nivestym, Nypozi, Nyvepria, Releuko, Rolvedon, Ryzneuta, Stimufend, Ziextenzo) - Rx (Self Administration) & Medical Benefits (Health Professional Administered) Open a PDF 06/17/2026
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
Duchenne Muscular Dystrophy (DMD) - (Agamree, Amondys 45, Duvyzat, Emflaza, Exondys 51, Kymbee, Viltepso and Vyondys 53) (Self-Administered) - Rx Benefit & (Health Professional Administered) - Medical Benefit Open a PDF 06/17/2026
Spinal Muscular Atrophy (SMA) - Medical Benefit (Evrysdi (risdiplam), Spinraza (nusinersen), Zolgensma (onasemnogene abeparovec-xioi)) Open a PDF 06/12/2026
Ryoncil (remestemcel-l-rknd) Drug Policy - (Health Professional Administered) - Medical Benefit Open a PDF 06/12/2026
Papzimeos™ (zopapogene imadenovec-drba) Drug Policy Open a PDF 06/12/2026
Omisirge (omidubicel-onlv) (Health Professional Administered) - Medical Benefit Open a PDF 06/12/2026
Lyfgenia (lovotibeglogene autotemcel) Drug Policy (Health Professional Administered) - Medical Benefit 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
Encelto (revakinagene taroretcel-lwey) Implant (Health Professional Administered) - Medical Benefit Open a PDF 06/12/2026
Elevidys (delandistrogene moxeparvovec-rokl) (Medicaid Managed Care, Essential Plan, Commercial, & Medicare) - Medical Benefit Open a PDF 06/12/2026
Chimeric Antigen Receptor T Cell (CAR-T) Therapy – (Health Professional Administered) (Abecma, Aucatzyl, Breyanzi, Carvykti, Kymriah, Tecartus, & Yescarta) - Medical Benefit Open a PDF 06/12/2026
Casgevy (exagamglogene autotemcel) Drug Policy (Health Professional Administered) - Medical Benefit Open a PDF 06/12/2026
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
Step Therapy Drug Policy Open a PDF 06/04/2026
Xiaflex - Medical Benefit (collagenase clostridium histolyticum) Policy Open a PDF 06/01/2026
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
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
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
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
Qalsody (tofersen) Drug Policy (Health Professional Administered) - Medical Benefit Open a PDF 06/01/2026
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
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
Ohtuvayre (ensifentrine) Policy for Commercial, Exchange, & SafetyNet - Rx Benefit; Medicare Advantage & DSNP - Medical Benefit Open a PDF 06/01/2026
Inborn Errors of Metabolism Policy (Rx & Medical Benefit) – (Attruby, Amvuttra, Brineura, Carbaglu and generic carglumic acid, Cerdelga, Cerezyme, Cholbam, Crysvita, Ctexli, Dojolvi, Elaprase, Elelyso, Elfabrio, Fabrazyme, Galafold, Givlaari, Harliku, Javygtor and generic sapropterin, Kanuma, Kuvan, Lamzede, Lumizyme, Mepsevii , Naglazyme, Nexviazyme, nitisinone capsule, Nityr, Nulibry, Olpruva, Onpattro, Orfadin, Oxlumo, Palynziq, Pombiliti, Ravicti , Rivfloza, Strensiq, Sucraid, Tegsedi, Vimizim, VPRIV, Vyndaqel, Vyndamax, Wainua, Xenpozyme, Xuriden, Yargesa & Zavesca) Open a PDF 06/01/2026
Immune Thrombocytopenia (ITP) Drug Policy (Alvaiz, Doptelet and Doptelet Sprinkle, eltrombopag tablet and powder for suspension, Nplate, Promacta, Tavalisse, Wayrilz) (Self-Administered & Health Professional Administered) – Rx Benefit & Medical Benefit Open a PDF 06/01/2026
Immune Checkpoint Inhibitor (CPI) (Health Professional Administered) - (Bavencio, Imfinzi, Imjudo, Jemperli, Keytruda, Keytruda Qlex, Libtayo, Loqtorzi, Opdivo, Optivo, Opdualag, Qvantig, Tecentriq, Tecentriq Hybreza, Tevimbra, Unloxcyt, Yervoy, and Zynyz) - Medical Benefit Open a PDF 06/01/2026
Hemophilia Gene Therapies Policy - (Hemgenix & Roctavian) - Medical Benefit Open a PDF 06/01/2026
Showing 1– 50 of 85 Results

 

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