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.

Beginning April 1, 2023, all Medicaid members enrolled in Blue Choice Option, HMO Blue Option, and Blue Option Plus will receive their prescription drugs 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 26– 50 of 73 Results
Title Last Updated
Growth Hormone Policy Open a PDF 01/08/2025
Headache Disorder – (Aimovig (erenumab-aooe) (Rx), Ajovy (fremanezumab-vfrm) (Rx & Medical), D.H.E 45, dihydroergotamine 1 mg/mL ampule (Rx), Elyxyb (celecoxib oral solution) Rx, Emgality 120 mg (galcanezumab-gnlm) (Rx), Emgality 300 mg (galcanezumab-gnlm) (Rx), Ergomar (ergotamine tartrate) Rx, Migranal, dihydroergotamine 4 mg/mL nasal spray, 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 01/02/2025
Hemophilia Gene Therapies Policy - (Beqvez, Hemgenix & Roctavian) - Medical Benefit Open a PDF 12/15/2024
Hereditary Angioedema (HAE) For Berinert, Cinryze, Firazyr, Icatibant Haegarda, Kalbitor, Orladeyo, Ruconest, Sajazir, and Takhzyro Open a PDF 01/01/2025
Immune Checkpoint Inhibitor (CPI) (Medical Benefit) (Health Professional Administered) - (Bavencio, Imfinzi, Imjudo, Jemperli, Keytruda, Libtayo, Loqtorzi, Opdivo, Opdualag, Tecentriq, Tecentriq Hybreza, Tevimbra, Yervoy, and Zynyz) Open a PDF 11/21/2024
Inborn Errors of Metabolism Policy (Rx & Medical Benefit) – (Attruby, Amvuttra, Brineura, Carbaglu and generic carglumic acid, Cerdelga, Cerezyme, Cholbam, Crysvita, Dojolvi, Elaprase, Elelyso, Elfabrio, Fabrazyme, Galafold, Givlaari, 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 12/23/2024
Infertility Medications Policy Open a PDF 09/13/2024
Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs - Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs - (Actemra - tocilizumab (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), 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 – guselkumab (Medical or Rx), Tyenne Actemra biosimilar), Xeljanz and Xeljanz XR- tofacitinib and tofacitinib ER (Rx), Zeposia- ozanimod (Rx)) Open a PDF 01/06/2025
Interleukin Antagonists for Asthma and Other Conditions - (Health Professional Administered) Medical Benefit & (Self-Administered) Rx Benefit - (Adbry, Cinqair, Dupixent, Ebglyss, Fasenra, Nemluvio, & Nucala) Open a PDF 01/01/2025
Intravenous Immune Globulin (IVIG) & Sub-Cutaneous Immune Globulin (SCIG) Therapy – (Health Professional Administered) Rx & Medical Benefit (Alyglo, Asceniv, Bivigam, Cutaquig, Cuvitru, Flebogamma, Gammagard Liquid, Gammagard S/D powder, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, & Xembify) Open a PDF 12/15/2024
Intravenous Iron Replacement Products Policy - Medical Benefit Open a PDF 09/13/2024
Lantidra (donislecel-jujn) - Medical Benefit (Commercial, Essential Plan, Medicaid Managed Care & Medicare) Open a PDF 12/15/2024
Low Clinical Impact Drugs - Rx Open a PDF 01/06/2025
Lyfgenia (lovotibeglogene autotemcel) Drug Policy - Medical Benefit Open a PDF 09/13/2024
Medicare Part B Step Therapy Drug List Open a PDF 01/01/2025
Medicare Part D 2025 Prior Authorization Policy Open a PDF 01/01/2025
Medicare Part D 2025 Step Therapy Policy Open a PDF 01/01/2025
Medicare Part D Formulary Level Cumulative Opioid and Opioid / Buprenorphine POS Edits Open a PDF 11/30/2023
Monoclonal Antibodies for the Treatment of Hemophilia – (Health Professional Administered) Medical Benefit & (Self-Administered) Rx Benefit - (Hemlibra and Hympavzi) Open a PDF 01/08/2025
Non-Formulary Medication Exception Review Policy Open a PDF 10/15/2024
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Policy - (celecoxib tablets, Coxanto, Diclofenac solution, diclofenac capsules & patches, diclofenac potassium tablets, dolobid 250mg tablets, fenoprofen capsules & tablets, Fenortho, Flector, Ibuprofen/famotidine, Indocin, indomethacin capsules, indomethacin suppositories, ketoprofen capsules, ketorolac/tromethamine nasal spray, kiprofen, Licart, Lofena, meloxicam capsules, Meloxicam oral suspension, nabumetone tablets, Nalfon, Naprelan, Naprosyn suspension, naproxen/esomeprazole tablets, naproxen ER, naproxen suspension, oxaprozin capsules, Relafen DS, Seglentis, Sprix, Tivorbex, Tolectin 600mg tablets, tramadol tablets, Vimovo, Vivlodex, Zipsor, & Zorvolex) Open a PDF 10/09/2024
Ocaliva (obeticholic acid) Drug Policy - Medical Benefit Open a PDF 01/01/2025
Off-Label Use of FDA Approved Drugs Open a PDF 09/06/2024
Oncology Biosimilar Drug Policy - (Avastin (bevacizumab) and Alymsys (bevacizumab-maly), Herceptin (trastuzumab), Herceptin Hylecta (trastuzumab and hyaluronidase-oysk), Hercessi (trastuzumab-strf), 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 01/08/2025
Oncology CRPA - Medical Benefit (Health Professional Administered) – (Abecma, Abraxane, Adcetris, Adstiladrin, Amtagvi, Anktiva, Arzerra, Asparlas, Beizray, Beleodaq, Belrapzo, Bendamustine HCL, Bendeka, Besponsa, Blincyto, Boruzu, Breyanzi, Camcevi, Carvykti, Colimvi, Cyramza, Danyelza, Darzalex., Darzalex Docivyx, Faspro, Elahere, Elitek, Elrexfio, Elzonris, Empliciti, Enhertu, Epkinly, Erwinaze, Folotyn, Fyarro, Gazyva, Hepzato Kit, Imdelltra, Infugem, Istodax, Jelmyto, Kadcyla, Kimmtrak, Kymriah, Kyprolis, Lartruvo, Leuprolide Acetate Depot, Lumoxiti, Lunsumio, Margenza, Monjuvi, Mylotarg, Omisirge, Oncaspar, Onivyde, Paclitaxel protein-bound particles, Padcev, Pedmark, Pemfexy, Pemrydi, Phesgo, Polivy, Portrazza, Posfrea, Poteligeo, Pralatrexate, Provenge, Romidepsin, Rybrevant, Rylaze, Rytelo, Sarclisa, Talvey, Tecartus, Tecelra, Tecvayli, Temsirolimus, Tivdak, Torisel, Treanda, Trodelvy, Vectibix, Vivimusta, Vyloy, Vyxeos, Xgeva, Yescarta, Yondelis, Zaltrap, Zepzelca, & Zynlonta) Open a PDF 12/10/2024
Showing 26– 50 of 73 Results

 

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