Prescription Drug Polices

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.

*Pharmacy benefit drugs - Excellus BlueCross BlueShield continues to manage the pharmacy benefit for Medicaid Managed Care and Child Health Plus members. Use the Excellus Pharmacy Management Drug Policies below.

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Showing 1– 25 of 58 Results
Title Last Updated
Spinal Muscular Atrophy (SMA) – Evrysdi (risdiplam), Spinraza (nusinersen), Zolgensma (onasemnogene abeparovec-xioi) Open a PDF 9/16/2021
Rare Disease Clinical Review Prior Authorization (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), Empaveli - pegcetacoplan (Medical & Rx), Enjaymo - sutimlimab-jome (Medical), Enspryng - satralizumab-mwge injection (Rx or Medical), Evkeeza - evinacumab-dgnb (Medical), Exservan and Tiglutik - riluzole oral film and oral suspension (Rx), Firdapse -amifampridine (Rx), Gamifant - emapalumab-lzsg (Medical), Ilaris - canakinumab (Medical), Increlex - mecasermin, Recombinant, rh-IGF -1 (Rx), Isturisa - osilodrostat tablets (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), Procysbi - cysteamine capsules and packets (Rx), Pyrukynd - mitapivat tablets (Rx), Radicava - edaravone (Rx/Medical), 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), Scenesse - afamelanotide (Medical), Signifor LAR - pasireotide (Medical), Signifor SC - pasireotide solution (Rx), Soliris - eculizumab (Medical), Somavert - pegvisomant (Rx), Sylvant - siltuximab (Medical), Syprine, Clovique, and generic trientine capsules (Rx), Tarpeyo -budesonide delayed release capsules (Rx), Tavneo s- avacopan (Rx), Tepezza - teprotumumab-trbw (Medical), Ultomiris - ravulizumab-cwvz injection (Medical), Uplizna - inebilizumab-cdon (Medical), Vijoice - alpelisib (Rx), Voxzogo - vosoritide (Rx), Vyvgart - efgartigimod alfa-fcab (Medical), Zokinvy - lonafarnib (Rx), and Ztalmy -ganaxolone (Rx)) Open a PDF 7/1/2022
Opioid Management Health & Safety Program Open a PDF 6/7/2022
Coronavirus (COVID-19) Impacted Drug Therapies (Hydroxychloroquine, Molnupiravir, Paxlovid, Stromectol) Open a PDF 6/7/2022
Step Therapy Policy Open a PDF 6/30/2022
Oncology Clinical Review Prior Authorization Rx Open a PDF 6/3/2022
Clinical Review Prior Authorization Rx (CRPA) Open a PDF 6/29/2022
Viscosupplementation with Hyaluronic Acid Open a PDF 6/28/2022
Tezspire™ (tezepelumab-ekko subcutaneous injection) Open a PDF 6/28/2022
Interleukin Antagonists for Asthma and Other Conditions: Nucala (mepolizumab), Cinqair (reslizumab), Fasenra (benralizumab), & Dupixent (dupilumab) Open a PDF 6/28/2022
Pulmonary Hypertension (PH) Open a PDF 6/24/2022
Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs PDF Open a PDF 6/24/2022
Oncology Biosimilar Drug Policy Open a PDF 6/21/2022
Quantity Limit Open a PDF 6/21/2022
Intravenous Immune Globulin (IVIG) & Sub-Cutaneous Immune Globulin (SCIG) Therapy Open a PDF 6/15/2022
Stelera (Ustekinumab) – for Crohn’s Disease, Plaque Psoriasis and Psoriatic Arthritis Open a PDF 6/1/2022
Inborn Errors of Metabolic Diseases (IEM) Open a PDF 5/9/2022
PDE-5 Inhibitor Drugs-Medical Necessity Review (MMC & HARP) Open a PDF 5/6/2021
Xolair (omalizumab) Open a PDF 5/5/2022
Hemlibra (emicizumab-kxwh) Open a PDF 5/5/2022
Antihemophilic Agents (For Managed Medicaid and HARP) Open a PDF 5/5/2022
Alpha-1 Antitrypsin Therapy (AAT) Open a PDF 5/5/2022
Off Label Use Open a PDF 5/5/2022
Clinical Review Prior Authorization (CRPA) Medical Drugs (Cablivi, Ceprotin, Hydroxyprogesterone, Krystexxa, Lemtrada, Leqvio, NPlate, Ocrevus, Saphnelo, Spravato, Trogarzo, Tysabri, Vabysmo, Zoladex, or any other Medical agent) Open a PDF 5/4/2022
Humira ® (adalimumab) – for Psoriasis, Rheumatoid Arthritis, Juvenile Idiopathic Arthritis, Psoriatic Arthritis, Ankylosing Spondylitis, Hidradenitis Suppurativa, Crohn’s Disease, Ulcerative Colitis and Panuveitis Open a PDF 5/31/2022
Showing 1– 25 of 58 Results
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