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 57 Results
Title Last Updated
Botulinum Toxin (Botox, Dysport, Myobloc, Xeomin) – For Medicaid Managed Care Essential Plan and Child Health Plus Open a PDF 9/22/2022
Duchenne Muscular Dystrophy (DMD): Amondys 45 (casimersen), Emflaza (deflazacort), Exondys 51 (eteplirsen), Viltepso (vilotarsen) and Vyondys 53 (golodirsen) Open a PDF 9/22/2022
Off Label Use Open a PDF 5/5/2022
Rare Diseases CRPA Policy - (Actimmune - Interferon Gamma - 1B (Medical & Rx), Aldurazyme - laronidase (Medical), Arcalyst - rilonacept (Rx), Bylvay - odevixibat (Rx), Camzyos - mavacamten capsules (Rx), Cuprimine and generic penicillamine capsules (Rx), Cuvrior - trientine (Rx), Daybue - trofinetide (Rx)Empaveli - pegcetacoplan (Medical & Rx), Enjaymo - sutimlimab-jome (Medical), Enspryng - satralizumab-mwge injection (Rx or Medical), Evkeeza - evinacumab-dgnb (Medical), Filspari - sparsentan (Rx), Firdapse - amifampridine (Rx), Gamifant - emapalumab-lzsg (Medical), Hyftor 0.2% gel - sirolimus topical gel (Rx), Ilaris - canakinumab (Medical), Increlex - mecasermin, Isturisa - osilodrostat tablets (Rx), Joenja – leniolisib (Rx), Juxtapid - lomitapide capsules (Rx), Keveyis - dichlorphenamide (Rx), Korlym - mifepristone tablets (Rx), Lanreotide Acetate Injection (Medical & Rx), Livmarli - maralixibat (Rx), Luxturna - voretigene neparvovec-rzyl (Medical), Myalept - metreleptin (Rx), Mycapssa octreotide acetate (Rx), Procysbi - cysteamine capsules and packets (Rx), Pyrukynd - mitapivat tablets (Rx), Reblozyl -luspatercept-aamt (Medical), Recorlev - levoketoconazole (Rx), Rethymic - allogeneic processed thymus tissue-agdc (Medical), Revcovi - elapegademase-lvlr (Medical & Rx), Ruzurgi - amifampridine (Rx), Ryplazim - plasminogen, human-tvm (Medical & Rx), Sandostatin LAR (Rx & Medical), Scenesse - afamelanotide (Medical), Signifor LAR - pasireotide (Medical), Signifor SC - pasireotide solution (Rx), Skyclarys - omaveloxolone (Rx), Skysona-elivaldogene autotemcel (Medical), Soliris - eculizumab (Medical), Somavert - pegvisomant (Rx), Sylvant - siltuximab (Medical), Syprine, generic trientine capsules (Rx), Tarpeyo - budesonide delayed release capsules (Rx), Tavneos - avacopan (Rx), Tepezza - teprotumumab-trbw (Medical), Thiola, Thiola EC and generic tiopronin (Rx), Ultomiris - ravulizumab-cwvz injection (Medical), Uplizna - inebilizumab-cdon (Medical), Vijoice - alpelisib (Rx), Voxzogo - vosoritide (Rx), Vyvgart - efgartigimod alfa-fcab (Medical), Zokinvy - lonafarnib (Rx), Ztalmy -ganaxolone (Rx), Zynteglo - betibeglogene (Rx)) Open a PDF 5/30/2023
Amyotrophic Lateral Sclerosis (ALS) Policy - (Exservan - riluzole oral film (Rx), Radicava and Radicava ORS - edaravone injection and kit (Rx/Medical), Relyvrio - sodium phenylbutyrate and taurursodiol (Rx), Tiglutik-riluzole oral suspension (Rx), & Qalsody-tofersen (Medical)) 5/30/2023
Clinical Review Prior Authorization Rx (CRPA) Open a PDF 5/30/2023
Coronavirus (COVID-19) Impacted Drug Therapies (Hydroxychloroquine, Lagevrio (molnupiravir), Paxlovid (nirmatrelvir/ritonavir), Stromectol (ivermectin)) Open a PDF 5/25/2023
Interleukin Antagonists for Asthma and Other Conditions: Nucala (mepolizumab), Cinqair (reslizumab), Fasenra (benralizumab), Dupixent (dupilumab), & Adbry (tralokinumab-ldrm) Open a PDF 5/25/2023
Weight Management - Contrave, Orlistat, Qsymia, Saxenda, Wegovy, Xenical Open a PDF 5/24/2023
Immune Checkpoint Inhibitor (CPI) Clinical Review Prior Authorization (CRPA) (Bavencio, Imfinzi, Imjudo, Jemperli, Keytruda, Libtayo, Opdivo, Tecentriq, Yervoy & Zynyz) Open a PDF 5/19/2023
Clinical Review Prior Authorization (Medical Benefit) - (Briumvi (ublituximab-xiiy) (Medical), Cablivi (caplacizumab-yhdp) (Rx & Medical), Ceprotin (Protein C Concentrate, Human) (Medical), Fensolvi (leuprolide acetate) (Medical), Hydroxyprogesterone Caproate Injection (Medical), Krystexxa (pegloticase) (Medical), Lemtrada (alemtuzumab) (Medical), Leqvio (inclisiran) (Medical), NPlate (romiplostim) (Medical), Ocrevus (ocrelizumab) (Medical), Rebyota (fecal microbiota,live-jslm) (Medical), Saphnelo (anifrolumab-fnia) (Medical), Spravato (esketamine nasal spray) (Medical), Sunlenca (lenacapavir) (Rx & Medical), Supprelin LA (histrelin acetate) (Medical), Syfovre (pegcetacoplan injection) (Medical), Triptodur (triptorelin) (Medical), Trogarzo (ibalizumab-uiyk) (Medical), Tysabri (natalizumab) (Medical), Tzield (teplizumab-mzwv) (Medical), Vabysmo (faricimab-svoa) (Medical), Zoladex (goserelin implant) (Medical), or any other medical agent) Open a PDF 5/18/2023
Oncology (CRPA) Medical - (Abecma, Abraxane (paclitaxel protein bound particles), Adcetris (brentuximab vedotin), Aliqopa (copanlisib), Arzerra (ofatumumab), Asparlas (calaspargase pegol-mknl), Beleodaq (belinostat), Belrapzo (bendamustine HCL), Bendeka (bendamustine HCL)*, Besponsa (inotuzumab ozogamicin), Blenrep (belantamab mafodotin-blmf), Blincyto (blinatumomab), Breyanzi, Camcevi (leuprolide mesylate), Carvykti, Cyramza (ramucirumab), Danyelza (naxitamab-gqgk), Darzalex (daratumumab), Darzalex Faspro (daratumumab and hyaluronidase-fihj), Elahere (mirvetuximab soravtansine-gynx), Elitek (rasburicase), Elzonris (tragraxofusp-erzs), Empliciti (elotuzumab), Enhertu (fam-trastuzumab deruxtecan-nxki), Erwinaze (asparaginase), Folotyn (pralatrexate), Fyarro (sirolimus protein-bound particles), Gazyva (obinutuzumab), Istodax (romidepsin), Jelmyto (mitomycin gel), Kadcyla (ado-trastuzumab emtansine), Kimmtrak (tebentafusp), Kymriah, Kyprolis (carfilzomib), Lartruvo (olaratumab injection), leuprolide Acetate Depot, Lumoxiti (moxetumomab pasudotox-tdfk), Lunsumio (mosunetuzumab-axgb), Margenza (margetuximab-cmkb), Marqibo (vincristine sulfate liposome injection), Monjuvi (tafasitamab-cxix), Mylotarg (gemtuzumab ozogamicin), Oncaspar (pegaspargase), Onivyde (irinotecan liposome injection), Padcev (enfortumab vedotin-ejfv), Pedmark (sodium thiosulfate), 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), Tecvayli (teclistamab), Tecartus, Tivdak (tisotumab vedotin-tftv), Torisel (temsirolimus), Treanda (bendamustine HCL), Trodelvy (sacituzumab govitecan-hziy), Vivimusta (bendamustine HCL), Vyxeos, (Daunorubicin/Cytarabine), Yescarta, Yondelis (trabectedin), Zaltrap (ziv-aflibercept), Zepzelca (lurbinectedin), Zynlonta (loncastuximab tesirine-lpyl) Open a PDF 5/18/2023
Oncology Clinical Review Prior Authorization Rx - (Abiraterone 500 mg tablet, Afinitor (everolimus), Disperz (everolimus), 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), 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), 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), Truseltiq (infigratinib), Tukysa (tucatinib), Turalio (pexidartinib), Valchlor (mechlorethamine), 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 5/18/2023
Blood Modifiers - (Cosela, Fulphila, Fylnetra, Granix, Neulasta, Neupogen, Nivestym, Nyvepria, Releuko, Rolvedon, Udenyca, Ziextenzo) Open a PDF 5/17/2023
Quantity Limit Open a PDF 5/12/2023
Inborn Errors of Metabolism - 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), 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 5/11/2023
Xolair (omalizumab) Open a PDF 5/11/2023
Pulmonary Hypertension (PH) - Adcirca (tadalafil (including Alyq)(Rx)), Adempas (riociguat (Rx)), Flolan, Veletri, (epoprostenol (Medical)), Letairis (ambrisentan (Rx)), Opsumit (macitentan (Rx)), Orenitram (treprostinil (Rx)), Remodulin (treprostinil (Medical)), Revatio (sildenafil (Rx)), Tracleer (bosentan (Rx)), Tyvaso (treprostinil) inhalation, Tyvaso DPI (Rx)), Uptravi (selexipag) Rx)), Ventavis (iloprost) inhalation (Medical)), & Combination Therapy (Ambrisentan and tadalafil) Open a PDF 5/11/2023
Opioid Management Health & Safety Program Open a PDF 5/11/2023
Hemlibra (emicizumab-kxwh) Open a PDF 5/11/2023
Chimeric Antigen Receptor T Cell (CAR-T) Therapy Open a PDF 5/11/2023
Antihemophilic Agents (For Managed Medicaid and HARP) Open a PDF 5/11/2023
Alpha-1 Antitrypsin Therapy (AAT) Open a PDF 5/11/2023
Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp) Open a PDF 5/11/2023
Generic Advantage Program / MAC Penalty Open a PDF 5/11/2022
Showing 1– 25 of 57 Results

 

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