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– 85 of 85 Results
Title Last Updated
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
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
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
Lantidra (donislecel-jujn) Drug Policy for Commercial, Essential Plan, Medicaid Managed Care & Medicare (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
Amyotrophic Lateral Sclerosis (ALS) Policy - (Qalsody, Radicava and Radicava ORS, Relyvrio, Teglutik & Tiglutik) (Self Administration) - Rx Benefit OR (Health Professional Administration) - Medical 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
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
Testosterone Drug Policy (Testopel, Aveed, & Azmiro) (Health Professional Administered) - Medical Benefit 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
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
Hemophilia Gene Therapies Policy - (Hemgenix & Roctavian) - Medical Benefit Open a PDF 06/01/2026
Geographic Atrophy Drug Policy (Izervay, Syfovre) (Health Professional Administered) - Medical Benefit Open a PDF 06/01/2026
Xolair (omalizumab) Drug Policy Open a PDF 06/01/2026
Kebilidi (eladocagene exuparvovec-tneq) (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
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
Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp) Open a PDF 05/14/2025
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
Patient Protection and Affordable Care Act (PPACA) - Preventive Items and Services Open a PDF 02/12/2026
Compounded Drug Products Policy Open a PDF 02/12/2026
Showing 51– 85 of 85 Results

 

GDPR Notification Content