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 73 Results
Title Last Updated
Site of Care Redirection for Medical Specialty Drug Administration Policy Open a PDF 01/01/2025
Medicare Part B Step Therapy Drug List Open a PDF 01/01/2025
Clinical Review Prior Authorization (CRPA) Rx Drug Policy Open a PDF 01/01/2025
Medicare Part D 2025 Step Therapy Policy Open a PDF 01/01/2025
Medicare Part D 2025 Prior Authorization Policy Open a PDF 01/01/2025
Viscosupplementation with Hyaluronic Acid - Medical Benefit (Durolane, Euflexxa, Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz, Synojoynt, Synvisc One, Triluron, TriVisc, Visco-3) Open a PDF 01/01/2025
Ocaliva (obeticholic acid) Drug Policy - Medical Benefit Open a PDF 01/01/2025
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 01/01/2025
Cimzia (Certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis and Rheumatoid Arthritis Open a PDF 01/01/2025
Osteoporosis - Medical Benefit (Evenity® (romosozumab-aqqg), Forteo® (teriparatide), Teriparatide, Prolia® (denosumab), Tymlos® (abaloparatide), Miacalcin injection®, calcitonin salmon injection) Open a PDF 01/01/2025
Adalimumab (Self-Administered - Rx benefit) (Humira® [adalimumab], Abrilada™[adalimumab-afzb], Amjevita™ [adalimumab-atto], Cyltezo®/ adalimumab-adbm [adalimumab-adbm], Hadlima™ [adalimumab-bwwd], Hulio®/adalimumab-fkjp [adalimumab-fkjp], Hyrimoz®/adalimumab-adaz [adalimumab-adaz], Idacio®/ adalimumab-aacf [adalimumab-aacf], Simlandi® (adalimumab-ryvk), Yuflyma® [adalimumab-aaty], Yusimry™ [adalimumab-aqvh]) Open a PDF 01/01/2025
Stelara (ustekinumab) – for Crohn’s Disease, Plaque Psoriasis and Psoriatic Arthritis Open a PDF 01/01/2025
Tezspire™ (tezepelumab-ekko subcutaneous injection) Open a PDF 01/01/2025
Xolair (omalizumab) Drug Policy Open a PDF 01/01/2025
Diabetic Incretin Mimetic Agents Policy Open a PDF 01/01/2025
Clinical Review Prior Authorization (CRPA) Policy - Medical Benefit for (Medicaid Managed Care, HARP, Essential Plan & Dual Special Needs Plan) - (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 01/01/2025
Hereditary Angioedema (HAE) For Berinert, Cinryze, Firazyr, Icatibant Haegarda, Kalbitor, Orladeyo, Ruconest, Sajazir, and Takhzyro Open a PDF 01/01/2025
Step Therapy Drug Policy - Acyclovir 5% cream, Adapalene 0.1% (Lotion, Soln, Swab), Admelog, Adlarity, AirDuo Digihaler, AirDuo Respiclick, Alogliptin, Alogliptin/metformin, Alogliptin/pioglitazone, Alvesco, Amitiza, Amzeeq, Anzemet, Apidra, Armonair Digihaler, Aspart Insulin, Aczone 7.5%, Bafiertam, Belsomra, Blood Glucose Meters and Test Strips, Budesonide/Formoterol, Caplyta, Clindagel 75 mL, Clindamycin 1% Gel 75 mL (Oceanside & Solaris), Dapsone 7.5%, Dayvigo, Denavir 1% Cream, Differin 0.1% Lotion, Doryx, Doryx MPC, Doxycycline hyclate DR, Drizalma Sprinkle, Duaklir Pressair, Ecoza, Edarbi, Edarbyclor, Edluar, Emsam, Ertaczo, Estring, Eucrisa Ointment, Fanapt, Fiasp, Flovent Diskus and Flovent HFA, Forfivo XL 450mg, Fortamet, Gelnique, Glumetza, Ibsrela, Insulin Aspart, Invokamet, Invokamet XR, Invokana, Januvia, Janumet and Janumet XR, Kazano, Latanoprost/PF, Livalo, Lonhala Magnair 25 mcg Refill & Starter, Luliconazole, Luzu, Lyuzeh, Metformin ER (generics of Fortamet and Glumetza), Metformin HCl 625 mg, Motegrity, Naftifine, Naftin Gel, Nesina, Nexletol, Nexlizet Norgesic Forte, Noritate, Novolin 70-30, Novolin N, Novolin R, Novolog, Novolog Mix 70/30, Omeprazole/Sodium Bicarbonate Packets, Onzetra Spray, Orphenadrine/Aspirin/Caffeine, Orphengesic Forte, Oseni, Osphena, Oxistat Lotion, Oxytrol, Pancreaze, Penciclovir 1% Cream, Pertzye, Pheburane, Ponvory, Praluent, Prograf Granules, Pulmicort Flexhaler, Qtern, Quviviq, Relistor Tablet, Restasis 0.05%, Restasis Multidose 0.05%, Rexulti, Rhopressa, Rocklatan, Savaysa, Sancuso, Savaysa, Savella, Secuado, Segluromet, Sernivo Lotion, Spiriva, Steglujan, Steglatro, Symproic, Tafluprost, Thalitone, Tosymra, Tudorza Pressair, Ultravate Lotion, Venlafaxine ER Tablets, Verdeso, Vraylar, Vumerity, Vyzulta, Xadago, Xelpros, Xerese 5%-1% Cream, Xolegel, Yupelri, Zegerid Packets, Zembrace, Zerviate, Zilxi 1.5%, Zioptan, Zolmitriptan Nasal Spray, Zomig Nasal Spray, Zolpimist, Zovirax 5% cream, Zuplenz, Zyclara 2.5% Cream Pump, Zyclara 3.75% Cream, Zyclara 3.75% Cream Pump, Zypitamag) Open a PDF 01/01/2025
Rare Diseases (CRPA) - Rx Benefits (Self-Administered) & Medical Benefits (Health Professional Administered) – (Actimmune, Arcalyst, Bylvay, Camzyos, Cuprimine, Cuvrior, Daybue, Empaveli, Enspryng, Fabhalta, Filspari, Filsuvez, Firdapse, generic penicillamine capsules, generic tiopronin, generic trientine capsules, Hyftor 0.2% gel, Ilaris, Imcivree, Increlex, Isturisa, Joenja, Juxtapid, Keveyis, Lanreotide Acetate Injection, Livmarli, Myalept, Mycapssa, Ormalvi, Piasky, Procysbi, Pyrukynd, Recombinant, Recorlev, rh-IGF-1, Revcovi, Ruzurgi, Ryplazim, Signifor SC, Skyclarys, Sohonos, Somavert, Syprine, Tarpeyo, Tavneos, Thiola, Thiola EC, Vijoice, Voxzogo, Zilbrysq, Zokinvy, & Ztalmy) Open a PDF 01/01/2025
Weight Related Comorbidities Policy - Overweight Obesity Cardiovascular Disease- Contrave, Orlistat, Qsymia, Saxenda, Wegovy, Xenical, Zepbound Open a PDF 01/02/2025
Headache Disorder – (Aimovig (erenumab-aooe) (Rx), Ajovy (fremanezumab-vfrm) (Rx & Medical), D.H.E 45, dihydroergotamine 1 mg/mL ampule (Rx), Elyxyb (celecoxib oral solution) Rx, Emgality 120 mg (galcanezumab-gnlm) (Rx), Emgality 300 mg (galcanezumab-gnlm) (Rx), Ergomar (ergotamine tartrate) Rx, Migranal, dihydroergotamine 4 mg/mL nasal spray, 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 01/02/2025
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, 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 01/06/2025
Low Clinical Impact Drugs - Rx Open a PDF 01/06/2025
Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs - Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs - (Actemra - tocilizumab (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 – guselkumab (Medical or Rx), Tyenne Actemra biosimilar), Xeljanz and Xeljanz XR- tofacitinib and tofacitinib ER (Rx), Zeposia- ozanimod (Rx)) Open a PDF 01/06/2025
Monoclonal Antibodies for the Treatment of Hemophilia – (Health Professional Administered) Medical Benefit & (Self-Administered) Rx Benefit - (Hemlibra and Hympavzi) Open a PDF 01/08/2025
Showing 1– 25 of 73 Results

 

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