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 74 Results
Title Last Updated
Quantity Limit Open a PDF 05/09/2025
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, Primlev, Nalocet, & generic oxycodone-APAP 5mg/300mg and oxycodone-APAP 10mg/300mg & oxycodone-APAP 2.5mg/300mg, and Roxybond Open a PDF 05/09/2025
Ryoncil (remestemcel-l-rknd) Drug Policy - (Health Professional Administered) - Medical Benefit Open a PDF 05/08/2025
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 05/08/2025
Medicare Part B Step Therapy Drug List Open a PDF 05/07/2025
Low Clinical Impact for Rx Drugs Policy Open a PDF 05/02/2025
Diabetic Incretin Mimetic Agents Policy Open a PDF 05/01/2025
Medicare Part D 2025 Step Therapy Policy Open a PDF 05/01/2025
Medicare Part D 2025 Prior Authorization Policy Open a PDF 05/01/2025
Dual Special Needs Plan (D-SNP) 2025 Step Therapy Policy Open a PDF 05/01/2025
Dual Special Needs Plan (D-SNP) 2025 Prior Authorization Policy Open a PDF 05/01/2025
Blood Modifiers - (Cosela, Fulphila, Fylnetra, Granix, Neupogen, Nivestym, Nypozi, Nyvepria, Releuko, Rolvedon, Stimufend, Ziextenzo) - Rx (Self Administration) & Medical Benefits (Health Professional Administered) Open a PDF 04/28/2025
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 04/28/2025
Clinical Review Prior Authorization (CRPA) Rx Drug Policy Open a PDF 04/28/2025
Clinical Review Prior Authorization (CRPA) Policy - Medical Benefit for (Medicaid Managed Care, HARP, Essential Plan & Dual Special Needs Plan) - Benlysta IV (Medical), (Briumvi (Medical), Cablivi (Rx & Medical), Ceprotin (Medical), Eylea (Medical), Eylea HD (Medical), Gonadotropin-releasing hormone (GnRH) Analogs, Hydroxyprogesterone Caproate Injection (Medical), Krystexxa (Medical), Lemtrada (Medical), Leqvio (Medical), NPlate (Medical), Ocrevus (Medical), Pavblu (Medical), Pemgarda (Medical), Ranibizumab (Medical), Rebyota (Medical), Saphnelo (Medical), Spravato (Medical), Tysabri (Medical), Vabysmo (Medical), Zilretta (Medical), & Zoladex (Medical)) Open a PDF 04/28/2025
Ustekinumab (Stelara [ustekinumab], Yesintek [ustekinumab-kfce], Steqeyma [ustekinumab-stba], Wezlana [ustekinumab-auub], ustekinumab-ttwe, Otulfi [ustekinumab-aauz], Pyzchiva [ustekinumab-ttwe]) Open a PDF 04/24/2025
Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs - (Actemra (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 (Medical or Rx), Tofidence (Medical), Tyenne (Medical & Rx), Xeljanz and Xeljanz XR- tofacitinib and tofacitinib ER (Rx), Zeposia- ozanimod (Rx)) Open a PDF 04/24/2025
Geographic Atrophy Drug Policy (Health Professional Administered) - Medical Benefit (Izervay, Syfovre) Open a PDF 04/22/2025
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 04/17/2025
Cimzia(certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis and Rheumatoid Arthritis (Self-Administered or Healthcare Professional Administered) - Rx Benefit or Medical Benefit Open a PDF 04/16/2025
Kebilidi (eladocagene exuparvovec-tneq) (Health Professional Administered) - Medical Benefit Open a PDF 04/14/2025
Rare Diseases CRPA Policy (Medical and Rx Benefits) - (Actimmune (Medical & Rx), Adzynma (Medical), Aldurazyme (Medical), Arcalyst (Rx), Bkemv (Medical), Bylvay (Rx), Camzyos (Rx), Crenessity (Rx), Cuprimine and generic penicillamine capsules (Rx), Cuvrior (Rx), Daybue (Rx), Empaveli (Rx), Enjaymo (Medical), Enspryng (Rx or Medical), Epysqli (Medical), Evkeeza (Medical), Fabhalta (Rx), Filspari (Rx), Firdapse (Rx), Gamifant (Medical), Hyftor 0.2% gel (Rx), Ilaris (Medical), Increlex (Rx), Isturisa (Rx), Joenja (Rx), Juxtapid (Rx), Keveyis (Rx), Korlym (Rx), Livmarli (Rx), Luxturna (Medical), Myalept (Rx), Mycapssa (Rx), Ormalvi (Rx), Piasky (Medical), Procysbi (Rx), Pyrukynd (Rx), Reblozyl (Medical), Recombinant (Rx), Recorlev (Rx), Rethymic (Medical), Revcovi - (Medical & Rx), rh-IGF-1 (Rx), Ryplazim (Medical & Rx), Rystiggo (Medical), Sandostatin LAR and octreotide intramuscular injection (Rx & Medical), Scenesse (Medical), Signifor LAR (Medical), Signifor SC (Rx), Skyclarys (Rx), Skysona (Medical), Sohonos (Rx), Soliris 2mg & 10mg (Medical), Somavert (Rx), Sylvant (Medical), Syprine, generic trientine capsules (Rx), Tarpeyo (Rx), Tavneos (Rx), Tepezza (Medical), Thiola, Thiola EC, and generic tiopronin (Rx), Tryngolza (Rx), Tzield (Medical), Ultomiris (Medical), Uplizna (Medical), Venxxiva Rx, Veopoz (Medical), Vijoice (Rx), Voxzogo (Rx), Voydeya (Rx), Vyjuvek (Medical), Vyvgart (Medical), Vyvgart Hytrulo (Medical), Xolremdi (Rx), Yorvipath (Rx), Zilbrysq (Rx), Zokinvy (Rx), Ztalmy (Rx), Zynteglo (Rx)) Open a PDF 04/11/2025
Off-Label Use of FDA Approved Drugs Open a PDF 04/09/2025
Oncology CRPA (Health Professional Administered) – Medical Benefit (Abecma, Abraxane, Adcetris, Adstiladrin, Amtagvi, Anktiva, Arzerra, Asparlas, Beizray, Beleodaq, Belrapzo, Bendamustine HCL, Bendeka, Besponsa, Bispecific T-Cell Engagers (BiTE), 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, Ivra, Jelmyto, Kadcyla, Kimmtrak, Kymriah, Kyprolis, Lartruvo, Leuprolide Acetate Depot, Lumoxiti, Lunsumio, Margenza, Monjuvi, Mylotarg, Niktimvo, 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 04/08/2025
Weight Related Comorbidities Policy - Overweight, Obesity, & Cardiovascular Disease - Contrave, Orlistat, Qsymia, Saxenda, Wegovy, Xenical, & Zepbound Open a PDF 04/04/2025
Showing 1– 25 of 74 Results

 

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