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.

Make a comment

We invite practitioners to review & comment on our policies.

Showing 51– 84 of 84 Results
Title Last Updated
Qalsody (tofersen) Drug Policy (Health Professional Administered) - Medical Benefit 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
Hemophilia Gene Therapies Policy - (Hemgenix & Roctavian) - Medical Benefit Open a PDF 06/01/2026
Headache Disorder – (Aimovig (erenumab-aooe) (Rx), Ajovy (fremanezumab-vfrm) (Rx & Medical), D.H.E 45, dihydroergotamine 1 mg/mL ampule (Rx), Emgality 120 mg (galcanezumab-gnlm) (Rx), Emgality 300 mg (galcanezumab-gnlm) (Rx), Migranal, dihydroergotamine 4 mg/mL nasal spray, Trudhesa (Rx), Nurtec ODT (rimegepant) (Rx), Qulipta (atogepant) (Rx), Reyvow (lasmiditan) (Rx), Ubrelvy (ubrogepant) (Rx), Vyepti (eptinezumab-jjmr) (Medical), Zavzpret (zavegepant) (Rx) & Quantity Limit Criteria for Ubrelvy, Nurtec ODT, Reyvow, and Zavzpret) Open a PDF 06/01/2026
Geographic Atrophy Drug Policy (Izervay, Syfovre) (Health Professional Administered) - Medical Benefit Open a PDF 06/01/2026
Gamma-Aminobutyric Acid (GABA) A Receptor Positive Modulators for Postpartum Depression (Zurzuvae (zuranolone capsules) (Self-Administration) – Rx Benefit Open a PDF 06/01/2026
Cimzia(certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis and Rheumatoid Arthritis (Self-Administered or Healthcare Professional Administered) - Rx Benefit or Medical Benefit Open a PDF 06/01/2026
Anti-Amyloid Directed Therapies Policy - (Aduhelm, Kisunla, and Leqembi) (Health Professional Administered) - Medical Benefit Open a PDF 06/01/2026
Xolair (omalizumab) Drug Policy 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
Off-Label Use of FDA Approved Drugs Open a PDF 06/01/2026
Kebilidi (eladocagene exuparvovec-tneq) (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
Remicade® (infliximab), Infliximab, Renflexis® (infliximab-abda), Avsola® (infliximab-axxq), Inflectra® (infliximab-dyyb) - (Health Professional Administered) - Medical Benefit Open a PDF 06/01/2026
Amyotrophic Lateral Sclerosis (ALS) Policy - (Qalsody, Radicava and Radicava ORS, Relyvrio, Teglutik & Tiglutik) - Medical & Rx Benefit Open a PDF 06/01/2026
Alpha-1 Antitrypsin Therapy (AAT); Alpha-1 Proteinase Inhibitors (Human) (Prolastin-C®, Zemaira®, Aralast NP® and Glassia®) (Health Professional Administered) - Medical Benefit Open a PDF 06/01/2026
Non-Formulary Medication Exception Review Policy Open a PDF 06/01/2026
Spravato® (esketamine) Nasal Spray Drug Policy Open a PDF 05/29/2026
Rezdiffra (resmetirom) Drug Policy (Self Administration) - Rx Benefit Open a PDF 05/14/2026
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
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
Enteral Nutrition Drug Policy Open a PDF 05/14/2026
Adalimumab (Humira® [adalimumab], Abrilada™[adalimumab-afzb], Amjevita™ [adalimumab-atto], Cyltezo®/ adalimumab-adbm [adalimumab-adbm], Hadlima™ [adalimumab-bwwd], [adalimumab-fkjp], Hyrimoz®/adalimumab-adaz [adalimumab-adaz], adalimumab-aacf [adalimumab-aacf], Simlandi®/ adalimumab-ryvk (adalimumab-ryvk), Yuflyma®/adalimumab-aaty [adalimumab-aaty], Yusimry™ [adalimumab-aqvh] Open a PDF 05/14/2026
Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp) Open a PDF 05/14/2025
Diabetic Incretin Mimetic Agents Drug Policy (Exenatide Pen, Victoza Pen, Liraglutide Pen, Ozempic Tablet, Ozempic Pen, Rybelsus Tablet, Trulicity Pen, Mounjaro Pen) (Self-Administered) – Rx Benefit Open a PDF 05/07/2026
Medicare Part D Formulary Level Cumulative Opioid and Opioid / Buprenorphine POS Edits Open a PDF 03/11/2025
Growth Hormone Drug Policy (Genotropin, Humatrope, Ngenla, Norditropin, Omnitrope, Serostim, Skytrofa, Sogroya, and Zomacton) (Self Adminiatered) - Rx Benefit Open a PDF 03/09/2026
Generic Advantage Program / MAC Penalty Open a PDF 02/20/2025
Patient Protection and Affordable Care Act (PPACA) - Preventive Items and Services Open a PDF 02/12/2026
Enbrel (etanercept) – for Ankylosing Spondylitis, Juvenile Idiopathic Arthritis, Plaque Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis Open a PDF 02/12/2026
Compounded Drug Products Policy Open a PDF 02/12/2026
Showing 51– 84 of 84 Results

 

GDPR Notification Content