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.

Showing 1– 50 of 84 Results
Title Last Updated
Oncology Clinical Review Prior Authorization (CRPA) Medical Drug Policy (Abraxane, Adcetris, Adstiladrin, Amtagvi, Anktiva, Arzerra, Asparlas, Aukelso, Avgemsi, Avopef, 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, Evdi, Elahere, Elitek, Elrexfio, Elzonris, Empliciti, Emrelis, Enhertu, Epkinly, Erwinaze, Favlyxa, Focinvez, Folotyn, Fosaprepitant, Fyarro, Gazyva, Gemcitabine, Hepzato Kit, Imdelltra, Infugem, Inlexzo, Istodax, Ivra, Jelmyto, Jubereq, 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 09/02/2026
Chimeric Antigen Receptor T Cell (CAR-T) Therapy – (Abecma, Aucatzyl, Breyanzi, Carvykti, Kymriah, Tecartus, & Yescarta) (Health Professional Administered)- Medical Benefit Open a PDF 09/02/2026
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 09/01/2026
Medicare Part B Step Therapy Drug List Open a PDF 09/01/2026
Medicare Part D 2026 Step Therapy Policy Open a PDF 09/01/2026
Dual Special Needs Plan (D-SNP) 2026 Prior Authorization Policy Open a PDF 09/01/2026
Medicare Part D 2026 Prior Authorization Policy Open a PDF 09/01/2026
Dual Special Needs Plan (D-SNP) 2026 Step Therapy Policy Open a PDF 09/01/2026
Interleukin Antagonists for Asthma and Other Conditions Drug Policy (Adbry, Bullous Pemphigoid, Cinqair, Dupixent, Ebglyss, Exdensur, Fasenra, Icotyde, Nemluvio, & Nucala) (Self-Administered) - Rx Benefit OR (Health Professional Administered) - Medical Benefit Open a PDF 08/31/2026
Low Clinical Impact for Rx Drugs Policy Open a PDF 08/31/2026
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) - Rx Benefit OR (Health Professional Administered) – Medical Benefit Open a PDF 08/28/2026
Intravenous Immune Globulin (IVIG) & Sub-Cutaneous Immune Globulin (SCIG) Therapy Drug Policy (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 OR (Health Professional Administered) - Medical Benefit Open a PDF 08/27/2026
Anti-Amyloid Directed Therapies Policy - (Aduhelm, Kisunla, and Leqembi) (Health Professional Administered) - Medical Benefit Open a PDF 08/27/2026
Oncology Clinical Review Prior Authorization (CRPA) Rx Drug Policy (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, Jideytro, 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 08/26/2026
Step Therapy Drug Policy Open a PDF 08/25/2026
Quantity Limit Drug Policy Open a PDF 08/25/2026
Weight Related Comorbidities for Overweight, Obesity, Noncirrhotic Metabolic Dysfunction - Associated Steatohepatitis (MASH) & Cardiovascular Disease Drug Policy (New Start and Recertification) (Contrave, Foundayo, Liraglutide, Orlistat, Qsymia, phentermine-topiramate ER, Saxenda, Wegovy, Xenical, & Zepbound) (Self-Administration) - Rx Benefit Open a PDF 08/24/2026
Generic Advantage Program / MAC Penalty Determinations Open a PDF 08/20/2025
Clinical Review Prior Authorization (CRPA) Rx Drug Policy Open a PDF 08/18/2026
Encelto (revakinagene taroretcel-lwey) Implant (Health Professional Administered) - Medical Benefit Open a PDF 08/14/2026
Qalsody (tofersen) Drug Policy (Health Professional Administered) - Medical Benefit Open a PDF 08/14/2026
Xiaflex (collagenase clostridium histolyticum) Drug Policy (Health Professional Administered) - Medical Benefit Open a PDF 08/13/2026
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) - Rx Benefit OR (Health Professional Administered) - Medical Benefit Open a PDF 08/13/2026
Tezspire™ (tezepelumab-ekko subcutaneous injection) Drug Policy (Self-Administered) - Rx Benefit OR (Health Professional Administered) - Medical Benefit Open a PDF 08/13/2026
Systemic Lupus Erythematosus (SLE) and Lupus Nephritis (LN) Drug Policy (Benlysta IV (benlimumab), Gazyva (obintuzumab), Lupkynis (voclosporin), and Saphnelo (anifrolumab-fnia) (Self-Administered) - Rx Benefit OR (Health Professional Administered) - Medical Benefit Open a PDF 08/13/2026
Rare Diseases Clinical Review Prior Authorization (CRPA) Drug 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), Increlex (Rx), Isturisa (Rx), Joenja (Rx), Juxtapid (Rx), Keveyis (Rx), Korlym (Rx), Livmarli (Rx), Luxturna (Medical), Myalept (Rx), Mycapssa (Rx), Myqorzo (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), Voyxact (Rx), Vyjuvek (Medica & Rxl), Vyvgart (Medical), Vyvgart Hytrulo (Medical), Xolremdi (Rx), Yartemlea (Medical), Yorvipath (Rx), Yuviwel (Rx), Zevaskyn (Medical), Zilbrysq (Rx), Zokinvy (Rx), Ztalmy (Rx), Zynteglo (Rx)) (Self-Administered) - Rx Benefit OR (Health Professional Administered) - Medical Benefit Open a PDF 08/13/2026
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)) (Self-Administered) - Rx Benefit OR (Health Professional Administered) - Medical Benefit Open a PDF 08/13/2026
Remicade® (infliximab), Infliximab, Renflexis® (infliximab-abda), Avsola® (infliximab-axxq), Inflectra® (infliximab-dyyb) (Health Professional Administered) - Medical Benefit Open a PDF 08/13/2026
Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Drug Policy - (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)) (Self-Administered) - Rx Benefit OR (Health Professional Administered) - Medical Benefit Open a PDF 08/13/2026
Infertility Medications Drug Policy (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 08/13/2026
Inborn Errors of Metabolism Drug Policy (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) (Self-Administered) - Rx Benefit OR (Health Professional Administered) - Medical Benefit Open a PDF 08/13/2026
Immune Checkpoint Inhibitor (CPI) (Bavencio, Imfinzi, Imjudo, Jemperli, Keytruda, Keytruda Qlex, Libtayo, Loqtorzi, Opdivo, Optivo, Opdualag, Qvantig, Tecentriq, Tecentriq Hybreza, Tevimbra, Unloxcyt, Yervoy, and Zynyz) (Health Professional Administered) - Medical Benefit Open a PDF 08/13/2026
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) (Self-Administered) - Rx Benefit OR (Health Professional Administered) - Medical Benefit Open a PDF 08/13/2026
Gamma-Aminobutyric Acid (GABA) A Receptor Positive Modulators for Postpartum Depression (Zurzuvae (zuranolone capsules) (Self-Administration) – Rx Benefit Open a PDF 08/13/2026
Enbrel (etanercept) – for Ankylosing Spondylitis, Juvenile Idiopathic Arthritis, Plaque Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis (Self-Administered) - Rx Benefit Open a PDF 08/13/2026
Cytomegalovirus (CMV) Policy (Livtencity (Rx) & Prevymis (Rx & Medical) (Self-Administered) - Rx Benefit & (Health Professional Administered) - Medical Benefit Open a PDF 08/13/2026
Cimzia (certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis & Rheumatoid Arthritis (Self-Administered) - Rx Benefit OR (Healthcare Professional Administered) - Medical Benefit Open a PDF 08/13/2026
Botulinum Toxin (Botox, Daxxify, Dysport, Myobloc, Xeomin) – for Medicaid Managed Care (MMC), Health and Recovery Program (HARP), Child Health Plus (CHP), Essential Plan (EP), Exchange Plans, Commercial, and Dual Eligible Special Needs Plan (D-SNP) (Health Professional Administered) - Medical Benefit Open a PDF 08/13/2026
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] (Self-Administration) - Rx Benefit Open a PDF 08/13/2026
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 08/07/2026
Osteoporosis Drug Policy – (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 08/06/2026
Parkinson Disease Drug Policy (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) (Self Administration) - Rx Benefit OR (Health Professional Administered) - Medical Benefit Open a PDF 08/04/2026
Hepatitis-C Virus (HCV) Infection (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) (Self Administered) - Rx Benefit Open a PDF 08/03/2026
Casgevy (exagamglogene autotemcel) Drug Policy (Health Professional Administered) - Medical Benefit Open a PDF 07/17/2026
Lyfgenia (lovotibeglogene autotemcel) Drug Policy (Health Professional Administered) - Medical Benefit Open a PDF 07/17/2026
Intravenous Iron Replacement Products Drug Policy (Injectafer (ferric carboxymaltose) (Health Professional Administered) – Medical Benefit Open a PDF 07/16/2026
Attention Deficit Hyperactivity Disorder (ADHD) Policy - Adzenys ER, Adzenys XR ODT, Azstarys, Cotempla XR ODT, Desoxyn, Dyanavel XR, Jornay PM, methylphenidate ER ODT (generic Cotempla ER ODT), Mydayis, Onyda XR, Qelbree, Quillichew ER, Quillivant, Xelstrym Open a PDF 07/13/2026
Site of Care Redirection for Medical Specialty Drug Administration Policy 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
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
Showing 1– 50 of 84 Results

 

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