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.

Make a Comment

We invite practitioners to review & comment on our policies.

Showing 1– 25 of 58 Results
Title Last Updated
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 04/01/2023
Patient Protection and Affordable Care Act - Preventive Items and Services Open a PDF 04/01/2023
Spinal Muscular Atrophy (SMA) – Evrysdi (risdiplam), Spinraza (nusinersen), Zolgensma (onasemnogene abeparovec-xioi) Open a PDF 07/01/2023
Generic Advantage Program / MAC Penalty Open a PDF 07/10/2023
Growth Hormone Policy Open a PDF 07/11/2023
Xolair (omalizumab) Open a PDF 07/13/2023
Tezspire™ (tezepelumab-ekko subcutaneous injection) Open a PDF 07/13/2023
Interleukin Antagonists for Asthma and Other Conditions: Nucala (mepolizumab), Cinqair (reslizumab), Fasenra (benralizumab), Dupixent (dupilumab), & Adbry (tralokinumab-ldrm) Open a PDF 07/13/2023
Intravenous Immune Globulin (IVIG) & Sub-Cutaneous Immune Globulin (SCIG) Therapy Open a PDF 07/14/2023
Antihemophilic Agents (For Managed Medicaid and HARP) Open a PDF 07/17/2023
Blood Modifiers - (Cosela, Fulphila, Fylnetra, Granix, Neulasta, Neupogen, Nivestym, Nyvepria, Releuko, Rolvedon, Udenyca, Ziextenzo) Open a PDF 07/28/2023
Compounded Drug Products Policy Open a PDF 08/11/2023
Off Label Use Open a PDF 08/17/2023
Viscosupplementation with Hyaluronic Acid Open a PDF 08/24/2023
Xiaflex (collagenase clostridium histolyticum) Policy Open a PDF 08/24/2023
Zulresso (brexanolone injection) for Postpartum Depression Open a PDF 08/24/2023
Enbrel (etanercept) – for Ankylosing Spondylitis, Juvenile Idiopathic Arthritis, Plaque Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis Open a PDF 08/24/2023
Remicade® (infliximab), Infliximab, Renflexis® (infliximab-abda) Open a PDF 08/24/2023
Stelara (ustekinumab) – for Crohn’s Disease, Plaque Psoriasis and Psoriatic Arthritis Open a PDF 08/24/2023
Headache Disorder – (Aimovig (erenumab-aooe) (Rx), Ajovy (fremanezumab-vfrm) (Rx & Medical), D.H.E 45, dihydroergotamine 1 mg/mL ampule (Rx), Emgality 120 mg (galcanezumab-gnlm) (Rx), Emgality 300 mg (galcanezumab-gnlm) (Rx), Migranal, dihydroergotamine 4 mg/mL nasal spray, Trudhesa (Rx), 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 08/24/2023
Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs - (Actemra - tocilizumab (Medical or Rx), Cibinqo - abrocitinib (Rx), Cosentyx - secukinumab (Rx), Entyvio – vedolizumab (Medical), 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), Xeljanz and Xeljanz XR- tofacitinib and tofacitinib ER (Rx), Zeposia- ozanimod (Rx)) Open a PDF 09/01/2023
Quantity Limit Open a PDF 09/11/2023
Infertility Medications Open a PDF 09/11/2023
Weight Management - Contrave, Orlistat, Qsymia, Saxenda, Wegovy, Xenical Open a PDF 09/12/2023
Oncology (CRPA) Medical - (Health Professional Administered) Abraxane, Adcetris, Adstiladrin, Aliqopa, Arzerra, Asparlas, Beleodaq, Belrapzo, Bendamustine HCL, Bendeka, Besponsa, Blincyto, Camcevi, Colimvi, Cyramza, Danyelza, Darzalex., Darzalex Faspro, Elahere, Elitek, Elrexfio, Elzonris, Empliciti, Enhertu, Epkinly, Erwinaze, Folotyn, Fyarro, Gazyva, Istodax, Jelmyto, Kadcyla, Kimmtrak, Kyprolis, Lartruvo, Leuprolide Acetate Depot, Lumoxiti, Lunsumio, Margenza, Marqibo, Monjuvi, Mylotarg, Omisirge, Oncaspar, Onivyde, Paclitaxel protein-bound particles, Padcev, Pedmark, Phesgo, Polivy, Portrazza, Poteligeo, Pralatrexate, Provenge, Romidepsin, Rybrevant, Rylaze, Sarclisa, Synribo, Talvey, Tecvayli, Tecartus, Tivdak, Torisel, Temsirolimus, Treanda, Trodelvy, Vyxeos, Vivimusta, Xgeva, Yondelis, Zaltrap, Zepzelca, Zynlonta Open a PDF 09/12/2023
Showing 1– 25 of 58 Results

 

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