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– 25 of 81 Results
Title Last Updated
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 12/17/2025
Gamma-Aminobutyric Acid (GABA) A Receptor Positive Modulators for Postpartum Depression (Self-Administered) - Rx Benefit Open a PDF 11/20/2025
Duchenne Muscular Dystrophy (DMD) - (Agamree, Amondys 45, Duvyzat, Emflaza, Exondys 51, Viltepso and Vyondys 53) (Self-Administered) - Rx Benefit & (Health Professional Administered) - Medical Benefit Open a PDF 11/20/2025
Xolair (omalizumab) Drug Policy Open a PDF 11/19/2025
Spinal Muscular Atrophy (SMA) - Medical Benefit (Evrysdi (risdiplam), Spinraza (nusinersen), Zolgensma (onasemnogene abeparovec-xioi)) Open a PDF 11/19/2025
Ryoncil (remestemcel-l-rknd) Drug Policy - (Health Professional Administered) - Medical Benefit Open a PDF 11/19/2025
Respiratory Syncytial Virus (RSV) Prophylaxis Drug Policy (Health Professional Administered) - Medical Benefit Open a PDF 11/19/2025
Monoclonal Antibodies for the Treatment of Hemophilia – (Health Professional Administered) Medical Benefit & (Self-Administered) Rx Benefit - (Alhemo, Hemlibra, Hympavzi, Qfitlia) Open a PDF 11/19/2025
Kebilidi (eladocagene exuparvovec-tneq) (Health Professional Administered) - Medical Benefit Open a PDF 11/19/2025
Intravenous Iron Replacement Products Policy - Medical Benefit Open a PDF 11/19/2025
Inborn Errors of Metabolism Policy (Rx & Medical Benefit) – (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) Open a PDF 11/19/2025
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) - Medical Benefit Open a PDF 11/19/2025
Blood Modifiers - (Cosela, Fulphila, Fylnetra, Granix, Neupogen, Nivestym, Nypozi, Nyvepria, Releuko, Rolvedon, Ryzneuta, Stimufend, Ziextenzo) - Rx (Self Administration) & Medical Benefits (Health Professional Administered) Open a PDF 11/19/2025
Antihemophilic Agents for Medicaid Managed Care (MMC), Health and Recovery Program (HARP), and Dual Eligible Special Needs Plan (D-SNP) Open a PDF 11/19/2025
Amyotrophic Lateral Sclerosis (ALS) Policy - (Qalsody, Radicava and Radicava ORS, Relyvrio, Teglutik & Tiglutik) - Medical & Rx Benefit Open a PDF 11/19/2025
Alpha-1 Antitrypsin Therapy (AAT) - Medical Benefit Open a PDF 11/19/2025
Quantity Limit Open a PDF 11/13/2025
Infertility Medications Policy Open a PDF 10/08/2025
Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp) Open a PDF 05/08/2025
Off-Label Use of FDA Approved Drugs Open a PDF 05/08/2025
Medicare Part D Formulary Level Cumulative Opioid and Opioid / Buprenorphine POS Edits Open a PDF 03/11/2025
Clinical Review Prior Authorization (CRPA) Rx Drug Policy Open a PDF 03/06/2026
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 03/05/2026
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) Open a PDF 03/05/2026
Intravenous Immune Globulin (IVIG) & Sub-Cutaneous Immune Globulin (SCIG) Therapy (Alyglo, Asceniv, Bivigam, Cutaquig, Cuvitru, Flebogamma, Gammagard Liquid, Gammagard S/D powder, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, & Xembify) (Self-Administered) - Rx Benefit & (Health Professional Administered) - Medical Benefit Open a PDF 03/05/2026
Showing 1– 25 of 81 Results

 

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