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.

Make a Comment

We invite practitioners to review & comment on our policies.

Showing 26– 50 of 64 Results
Title Last Updated
Hemlibra (emicizumab-kxwh) Open a PDF 12/15/2022
Hereditary Angioedema (HAE) For Berinert, Cinryze, Firazyr, Icatibant Haegarda, Kalbitor, Orladeyo, Ruconest, Sajazir, and Takhzyro Open a PDF 3/15/2023
Immune Checkpoint Inhibitor (CPI) (Health Professional Administered) - (Bavencio, Imfinzi, Imjudo, Jemperli, Keytruda, Libtayo, Opdivo, Opdualag, Tecentriq, Yervoy, and Zynyz) Open a PDF 11/01/2023
Inborn Errors of Metabolism & Rare Genetic Diseases - Amvuttra (vutrisiran), Brineura (cerliponase alfa), Carbaglu and generic carglumic acid, Cerdelga (eliglustat), Cerezyme (imiglucerase), Cholbam (cholic acid), Crysvita (burosumab-twza), Dojolvi (tripheptanoin oral liquid), Elaprase (idursulfase), Elelyso (taliglucerase alfa), Fabrazyme (agalisidase beta), Galafold (migalastat), Givlaari (givosiran) –, Javygtor and generic sapropterin, Kanuma (sebelipase alfa), Kuvan, Lamzede, Lumizyme (alglucosidase alfa), Mepsevii (vestronidase alfa-vjbk), Naglazyme (galsulfase), Nexviazyme (avalglucosidase alfa-ngpt), nitisinone capsule, Nityr (nitisinone) and Orfadin (nitisinone), Nulibry (fosdenopterin), Onpattro (patisiran), Oxlumo (lumasiran), Palynziq (pegvaliase-pqpz), Pombiliti (cipaglucosidase alfa-ATGA), (Ravicti (glycerol phenylbutyrate), Strensiq (asfotase alfa), Sucraid (sacrosidase), Tegsedi (inotersen), Vimizim (elosulfase alfa)-Vimizim (elosulfase alfa), VPRIV (velaglucerase alfa), Vyndaqel (tafamidis meglumine), Vyndamax (tafamidis), Xenpozyme (olipudase alfa-rpcp), Xuriden (uridine triacetate), Zavesca / miglustat Open a PDF 11/10/2023
Infertility Medications Open a PDF 09/11/2023
Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs - (Actemra - tocilizumab (Medical or Rx), Cibinqo - abrocitinib (Rx), Cosentyx - secukinumab (Rx), Entyvio – vedolizumab (Medical), 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), Xeljanz and Xeljanz XR- tofacitinib and tofacitinib ER (Rx), Zeposia- ozanimod (Rx)) Open a PDF 10/25/2023
Interleukin Antagonists for Asthma and Other Conditions: Nucala (mepolizumab), Cinqair (reslizumab), Fasenra (benralizumab), Dupixent (dupilumab), & Adbry (tralokinumab-ldrm) Open a PDF 07/13/2023
Intravenous Immune Globulin (IVIG) & Sub-Cutaneous Immune Globulin (SCIG) Therapy Open a PDF 10/24/2023
Medicare D Formulary-Level Cumulative Opioid and Opioid / Buprenorphine POS Edits Open a PDF 11/15/2023
Medicare Part D 2023 Prior Authorization Policy Open a PDF 11/30/2023
Medicare Part D 2023 Step Therapy Policy Open a PDF 11/30/2023
Medicare Part D 2024 Prior Authorization Policy Open a PDF 10/16/2023
Medicare Part D 2024 Step Therapy Open a PDF 10/16/2023
Non-Formulary Medication Exception Review Policy Open a PDF 11/10/2023
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) - (Duexis, fenoprofen tablets, Flector, Licart, Lofena, diclofenac patches, indomethacin capsules, indomethacin suppositories, ketoprofen capsules, Naprelan, naproxen ER, naproxen suspension, Pennsaid, Qmiiz, Relafen DS, Seglentis, Sprix, ketorolac/tromethamine nasal spray, Tivorbex, Vimovo, Vivlodex, meloxicam capsules, Xelstrym, Zipsor, Zorvolex and diclofenac 35 mg capsules) Open a PDF 8/24/2023
Off Label Use Open a PDF 11/20/2023
Oncology (CRPA) Medical (Health Professional Administered) – Abraxane (paclitaxel protein-bound particles), Paclitaxel protein-bound particles (generic Abraxane), Paclitaxel protein-bound particles (American Regent 505(b)(2)), Adstiladrin (nadofaragene firadenovec-vncg), Adcetris (brentuximab vedotin), Aliqopa (copanlisib) Arzerra (ofatumumab), Asparlas (calaspargase pegol-mknl), Beleodaq (belinostat), Belrapzo (bendamustine HCL), Bendamustine HCL (Apotex 505(b)(2)), Bendamustine HCL (Baxter 505(b)(2)), Bendeka (bendamustine HCL, Bendeka (bendamustine HCL, Bendamustine HCL (generic Treanda), Vivimusta (bendamustine HCL), Besponsa (inotuzumab ozogamicin), Blincyto (blinatumomab), Camcevi (leuprolide mesylate), Columvi (glofitamab-gxbm) Cyramza (ramucirumab), Danyelza (naxitamab-gqgk), Darzalex (daratumumab), Darzalex Faspro (daratumumab and hyaluronidase-fihj), Elahere (mirvetuximab soravtansine-gynx), Elitek (rasburicase), Elrexfio (elranatamab-bcmm), Elzonris (tragraxofusp-erzs), Empliciti (elotuzumab), Enhertu (fam-trastuzumab deruxtecan-nxki), Epkinly (epcoritamab-bysp), Erwinaze (asparaginase), Folotyn (pralatrexate), Pralatrexate (generic Folotyn), Fyarro (sirolimus protein-bound particles), Gazyva (obinutuzumab), Infugem (gemcitabine), Istodax (romidepsin), Romidepsin (generic Istodax), Romidepsin (branded), Jelmyto (mitomycin gel), Kadcyla (ado-trastuzumab emtansine), Kimmtrak (tebentafusp), Kyprolis (carfilzomib), Lartruvo (olaratumab injection), Leuprolide Acetate Depot, Lumoxiti (moxetumomab pasudotox-tdfk), Lunsumio (mosunetuzumab-axgb), Margenza (margetuximab-cmkb), Monjuvi (tafasitamab-cxix), Mylotarg (gemtuzumab ozogamicin), Omisirge (omidubicel-onlv), Oncaspar (pegaspargase), Onivyde (irinotecan liposome injection), Padcev (enfortumab vedotin-ejfv), Pedmark (sodium thiosulfate), Pemfexy (pemetrexed), Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf), Polivy (polatuzumab vedotin-piiq), Portrazza (necitumumab), Poteligeo (mogamulizumab-kpkc), Provenge (sipuleucel-T), Rybrevant (amivantamab-vmjw), Rylaze (asparaginase erwinia chrysanthemi [recombinant]-rywn), Sarclisa (isatuximab-irfc) Synribo (omacetaxine mepesuccinate), Talvey (talquetamab-tgvs), Tecvayli (teclistamab), Tivdak (tisotumab vedotin-tftv), Torisel (temsirolimus), Temsirolimus (generic Torisel), Trodelvy (sacituzumab govitecan-hziy), Vyxeos (Daunorubicin/Cytarabine), Xgeva (denosumab), Yondelis (trabectedin), Zaltrap (ziv-aflibercept), Zepzelca (lurbinectedin), Zynlonta (loncastuximab tesirine-lpyl) Open a PDF 11/20/2023
Oncology Biosimilar Drug Policy - (Avastin (bevacizumab) and Alymsys (bevacizumab-maly), Herceptin (trastuzumab), Herceptin Hylecta (trastuzumab and hyaluronidase-oysk), Ogivri (trastuzumab-dkst), Ontruzant (trastuzumab-dttb), and Herzuma (trastuzumab-pkrb), Rituxan (rituximab), Rituxan Hycela (rituximab hyaluronidase), Riabni (rituximab-arrx) and Vegzelma (bevacizumab-adcd) (Medical)) Open a PDF 3/20/2023
Oncology Clinical Review Prior Authorization Rx (Self Administration) - (Abiraterone 500 mg tablet, Afinitor (everolimus), Akeega (niraparib tosylate monohydrate and abiraterone acetate), Alecensa (alectinib), Alunbrig (brigatinib), Ayvakit (avapritinib), Balversa (erdafitinib), Besremi (ropeginterferon alfa-2b-njft), (NOTE: both Rx and Medical benefit drug), Bosulif (bosutinib), Braftovi (encorafenib), Brukinsa (zanubrutinib), Cabometyx (cabozantinib tablets), Calquence (acalabrutinib), Caprelsa (vandetanib), Cometriq (cabozantinib capsules), Copiktra (duvelisib), Cotellic (cobimetinib), Daurismo (glasdegib), Disperz (everolimus), Erivedge (vismodegib), Erleada (apalutamide), Exkivity (mobocertinib), Fotivda (tivozanib), Gavreto (pralsetinib), Gilotrif (afatinib), Hemady (dexamethasone), Ibrance (palbociclib), Iclusig (ponatinib), Idhifa (enasidenib), Imbruvica (ibrutinib), Inlyta (axitinib), Inqovi (decitabine/cedazuridine), Inrebic (fedratinib), Iressa (gefitinib), Jakafi (ruxolitinib), Jaypirca (pirtobrutinib), Kisqali and Kisqali Femara Co-Pack (ribociclib and ribociclib/letrozole), Koselugo (selumetinib), Krazati (adagrasib), Lenvima (lenvatinib), Lonsurf (trifluridine and tipiracil), Lorbrena (lorlatinib), Lumakras (sotorasib), Lynparza tablets (olaparib tablets), Lytgobi (futibatinib), Mekinist (trametinib), Mektovi (binimetinib), Nerlynx (neratinib), Nexavar (sorafenib), Sorafenib (generic Nexavar), Ninlaro (ixazomib), Nubeqa (darolutamide), Odomzo (sonidegib), Ojjaara (momelotinib), Onureg (oral azacitidine), Orgovyx (relugolix), Orserdu (elacestrant), Pemazyre (pemigatinib), Piqray (alpelisib), Pomalyst (pomalidomide), Purixan (6-mercaptopurine), Qinlock (ripretinib), Retevmo (selpercatinib), Revlimid (lenalidomide), Rezlidhia (olutasidenib), Rezurock (belumosudil), Rozlytrek (entrecetinib), Rubraca (rucaparib), Rydapt (midostaurin), Scemblix (asciminib), Soltamox (tamoxifen citrate), Sprycel (dasatinib), Stivarga (regorafenib), Sutent (sunitinib), Tabrecta (capmatinib), Tafinlar (dabrafenib), Tagrisso (osimertinib), Talzenna (talazoparib), Tarceva (erlotinib), Targretin capsules (bexarotene capsules), Targretin gel (bexarotene gel), Tasigna (nilotinib), Tazverik (tazemetostat), Tepmetko (tepotinib), Tibsovo (ivosidenib), Tukysa (tucatinib), Turalio (pexidartinib), Valchlor (mechlorethamine), Vanflyta (quizartinib), Venclexta (venetoclax), Verzenio (abemaciclib), Vitrakvi (larotrectinib), Vizimpro (dacomitinib), Vonjo (pacritinib), Votrient (pazopanib), Welireg (belzutifan), Xalkori (crizotinib), Xermelo (telotristate ethyl), Xospata (gileritinib), Xpovio (selinexor), Xtandi (enzalutamide), Yonsa (abiraterone acetate, micronized), Zejula (niraparib), Zelboraf (vemurafenib), Zolinza (vorinostat), Zydelig (idelalisib), Zykadia (ceritinib), Zytiga (abiraterone acetate)) Open a PDF 11/20/2023
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, Oxaydo, Prolate Solution & Generic oxycodone-APAP 100-300mg/5ml, Prolate tablets, Primlev, Nalocet, & generic oxycodone-APAP 5mg/300mg and oxycodone-APAP 10mg/300mg & oxycodone-APAP 2.5mg/300mg, Roxybond, and Transmucosal Immediate-Release Fentanyl (TIRF) Medications) Open a PDF 09/19/2023
Osteoporosis - Evenity® (romosozumab-aqqg), Forteo® (teriparatide), Teriparatide, Prolia® (denosumab), Tymlos® (abaloparatide), Miacalcin injection®, calcitonin salmon injection Open a PDF 12/01/2023
Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp) Open a PDF 5/11/2023
Patient Protection and Affordable Care Act - Preventive Items and Services Open a PDF 04/01/2023
Pulmonary Hypertension (PH) - Adcirca (tadalafil (including Alyq)(Rx)), Adempas (riociguat (Rx)), epoprostenol (Medical)), Flolan, Letairis (ambrisentan (Rx)), Liqrev, Opsumit (macitentan (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)), & Combination Therapy (Ambrisentan and tadalafil) Open a PDF 6/8/2023
Quantity Limit Open a PDF 09/11/2023
Showing 26– 50 of 64 Results

 

GDPR Notification Content