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.

*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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We invite practitioners to review & comment on our policies.

Showing 1– 25 of 56 Results
Title Last Updated
Botulinum Toxin (Botox, Dysport, Myobloc, Xeomin) – For Medicaid Managed Care Essential Plan and Child Health Plus Open a PDF 07/13/2022
Medicare D 2022 Step Therapy Open a PDF 08/01/2022
Medicare D 2022 Prior Authorization Policy Open a PDF 08/01/2022
Synagis® (Palivizumab): Respiratory Syncytial Virus (RSV) Prophylaxis Open a PDF 1/28/2022
Medicare D Formulary-Level Cumulative Opioid and Opioid / Buprenorphine POS Edits Open a PDF 11/18/2021
Infertility Medications Open a PDF 11/19/2021
Osteoporosis - Evenity® (romosozumab-aqqg), Forteo® (teriparatide), Teriparatide, Prolia® (denosumab), Tymlos® (abaloparatide), Miacalcin injection®, calcitonin salmon injection Open a PDF 2/10/2022
Hereditary Angioedema (HAE) Open a PDF 2/10/2022
Compounded Drug Products Open a PDF 2/10/2022
Patient Protection and Affordable Care Act - Preventive Items and Services Open a PDF 2/10/2022
Repository Corticotropin Injection - for Infantile Spasms, Multiple Sclerosis Exacerbations Open a PDF 2/10/2022
Growth Hormone Open a PDF 2/10/2022
Sickle Cell Disease Management Policy Open a PDF 2/14/2022
Remicade (infliximab), Renflexis (infliximab-adba), Avsola (infliximab-axxq) Open a PDF 2/21/2022
Enbrel (etanercept) – for Ankylosing Spondylitis, Juvenile Idiopathic Arthritis, Plaque Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis Open a PDF 2/21/2022
Chronic Hepatitis C (Pegasys, Peg-Intron, ribavirin, Sovaldi, Harvoni, ledipasvir/sofosbuvir, Zepatier, Epclusa, sofosbuvir/velpatasvir, Vosevi, Mavyret) for Commercial, NYSOH Individual Market, NYSOH Employer Group Market Products, and Managed Medicaid products (Vosevi only) Open a PDF 3/16/2022
Duchenne Muscular Dystrophy (DMD): Amondys 45 (casimersen), Emflaza (deflazacort), Exondys 51 (eteplirsen), Viltepso (vilotarsen) and Vyondys 53 (golodirsen) Open a PDF 3/31/2022
PCSK9 Inhibitors Open a PDF 3/8/2022
Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp) Open a PDF 4/26/2022
Chimeric Antigen Receptor T Cell (CAR-T) Therapy Open a PDF 4/26/2022
Blood Modifiers Open a PDF 4/26/2022
Cimzia (Certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis and Rheumatoid Arthritis Open a PDF 4/4/2022
Immune Checkpoint Inhibitor (CPI) Clinical Review Prior Authorization (CRPA) (Bavencio, Imfinzi, Jemperli, Keytruda, Libtayo, Opdivo, Tecentriq, and Yervoy) Open a PDF 4/6/2022
Attention Deficit Hyperactivity Disorder (ADHD) Stimulants Policy Open a PDF 5/11/2022
Generic Advantage Program / MAC Penalty Open a PDF 5/11/2022
Showing 1– 25 of 56 Results
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