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 1– 25 of 62 Results
Title Last Updated
Anti-Amyloid Directed Therapies Policy (Aduhelm (aducanumab-avwa) & Leqembi (lecanemab-irmb)) Open a PDF 9/7/2023
Alpha-1 Antitrypsin Therapy (AAT) Open a PDF 3/20/2023
Quantity Limit Open a PDF 2/8/2024
Intravenous Iron Replacement Products Policy Open a PDF 2/1/2024
Adalimumab (Humira® [adalimumab], Abrilada (adalimumab-afzb), Amjevita™ [adalimumab-atto], Cyltezo® [adalimumab-adbm], Hadlima™ [adalimumab-bwwd], Hulio®/adalimumab-fkjp [adalimumab-fkjp], Hyrimoz®/adalimumab-adaz [adalimumab-adaz], Idacio® [adalimumab-aacf], Yuflyma® [adalimumab-aaty], Yusimry™ [adalimumab-aqvh] Open a PDF 12/19/2023
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 12/13/2023
Botulinum Toxin (Botox, Daxxify, Dysport, Myobloc, Xeomin) – for Medicaid Managed Care, Essential Plan, Child Health Plus, and Dual Eligible Special Needs Plan (D-SNP) Open a PDF 12/1/2023
Chronic Hepatitis C (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) Open a PDF 12/06/2023
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 12/06/2023
Xolair (omalizumab) Open a PDF 12/06/2023
Stelara (ustekinumab) – for Crohn’s Disease, Plaque Psoriasis and Psoriatic Arthritis Open a PDF 12/06/2023
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 12/06/2023
Hemlibra (emicizumab-kxwh) Open a PDF 12/06/2023
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 12/06/2023
Cimzia (Certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis and Rheumatoid Arthritis Open a PDF 12/06/2023
Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp) Open a PDF 12/06/2023
Infertility Medications Open a PDF 12/06/2023
Enbrel (etanercept) – for Ankylosing Spondylitis, Juvenile Idiopathic Arthritis, Plaque Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis Open a PDF 12/06/2023
Respiratory Syncytial Virus (RSV) Prophylaxis Open a PDF 11/30/2023
Medicare D Formulary-Level Cumulative Opioid and Opioid / Buprenorphine POS Edits Open a PDF 11/30/2023
Non-Formulary Medication Exception Review Policy Open a PDF 11/30/2023
Off Label Use Open a PDF 11/20/2023
Chimeric Antigen Receptor T Cell (CAR-T) Therapy Open a PDF 11/15/2022
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) - (celecoxib tablets, Coxanto, Diclofenac solution, diclofenac capsules & patches, diclofenac potassium tablets, fenoprofen capsules & tablets, Fenortho, Flector, Ibuprofen/famotidine, Indocin, indomethacin capsules, indomethacin suppositories, ketoprofen capsules, ketorolac/tromethamine nasal spray, 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, tramadol tablets, Vimovo, Vivlodex, Zipsor, & Zorvolex) Open a PDF 1/30/2024
Weight Management - Contrave, Orlistat, Qsymia, Saxenda, Wegovy, Xenical, Zepbound Open a PDF 1/26/2024
Showing 1– 25 of 62 Results

 

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