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 71 Results
Title Last Updated
Growth Hormone Policy Open a PDF 05/09/2024
Intravenous Immune Globulin (IVIG) & Sub-Cutaneous Immune Globulin (SCIG) Therapy – (Health Professional Administered) Rx & Medical Benefit (Alyglo, Asceniv, Bivigam, Cutaquig, Cuvitru, Flebogamma, Gammagard Liquid, Gammagard S/D powder, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, & Xembify) Open a PDF 06/20/2024
Osteoporosis - Medical Benefit (Evenity® (romosozumab-aqqg), Forteo® (teriparatide), Teriparatide, Prolia® (denosumab), Tymlos® (abaloparatide), Miacalcin injection®, calcitonin salmon injection) Open a PDF 06/20/2024
Xolair (omalizumab) Drug Policy Open a PDF 06/24/2024
Tezspire™ (tezepelumab-ekko subcutaneous injection) Open a PDF 06/24/2024
Interleukin Antagonists for Asthma and Other Conditions - Medical Benefit (Nucala (mepolizumab), Cinqair (reslizumab), Fasenra (benralizumab), Dupixent (dupilumab), & Adbry (tralokinumab-ldrm)) Open a PDF 07/05/2024
Pulmonary Hypertension (PH) Drug Policy- Adcirca (tadalafil (including Alyq)(Rx)), Adempas (riociguat (Rx)), epoprostenol (Medical)), Flolan, Letairis (ambrisentan (Rx)), Liqrev, Opsumit (macitentan (Rx)), Opsynvi (macitentan & tadalafil (Rx)), Orenitram (treprostinil (Rx)), Remodulin (treprostinil (Medical)), Revatio (sildenafil (Rx)), Tadliq (Rx)), Tracleer (bosentan (Rx)), Tyvaso (treprostinil) inhalation (Rx), Tyvaso DPI (Rx)), Uptravi (selexipag) Rx)), Veletri (Medical), Ventavis (iloprost) inhalation (Medical)), & Combination Therapy (Ambrisentan and tadalafil) Open a PDF 07/09/2024
Generic Advantage Program / MAC Penalty Open a PDF 07/10/2023
Remicade® (infliximab), Infliximab, Renflexis® (infliximab-abda) - Medical Benefit Open a PDF 08/15/2024
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 08/15/2024
Stelara (ustekinumab) – for Crohn’s Disease, Plaque Psoriasis and Psoriatic Arthritis Open a PDF 08/15/2024
Enbrel (etanercept) – for Ankylosing Spondylitis, Juvenile Idiopathic Arthritis, Plaque Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis Open a PDF 08/15/2024
Amyotrophic Lateral Sclerosis (ALS) Policy - (Exservan, Qalsody, Radicava and Radicava ORS, Relyvrio, Teglutik, & Tiglutik) - Medical & Rx Benefit Open a PDF 08/20/2024
Qalsody (tofersen) Policy - Medical Benefit Open a PDF 08/20/2024
Alpha-1 Antitrypsin Therapy (AAT) - Medical Benefit Open a PDF 08/21/2024
Patient Protection and Affordable Care Act (PPACA) - Preventive Items and Services Open a PDF 09/02/2024
Elevidys (delandistrogene moxeparvovec-rokl) - Medical Benefit (Medicaid Managed Care, Essential Plan, Commercial, & Medicare) Open a PDF 09/04/2024
Off-Label Use of FDA Approved Drugs Open a PDF 09/06/2024
Botulinum Toxin (Botox, Daxxify, Dysport, Myobloc, Xeomin) – for Medicaid Managed Care (MMC), Health and Recovery Program (HARP), Child Health Plus (CHP), Essential Plan (EP), and Dual Eligible Special Needs Plan (D-SNP) - Medical Benefit Open a PDF 09/13/2024
Xiaflex - Medical Benefit (collagenase clostridium histolyticum) Policy Open a PDF 09/13/2024
Weight Management Policy - Contrave, Orlistat, Qsymia, Saxenda, Wegovy, Xenical, Zepbound Open a PDF 09/13/2024
Spinal Muscular Atrophy (SMA) - Medical Benefit (Evrysdi (risdiplam), Spinraza (nusinersen), Zolgensma (onasemnogene abeparovec-xioi)) Open a PDF 09/13/2024
Rezdiffra (resmetirom) Drug Policy Open a PDF 09/13/2024
Respiratory Syncytial Virus (RSV) Prophylaxis - Medical Benefit Open a PDF 09/13/2024
Repository Corticotropin Injection (Medical & Rx Benefit) (Acthar HP and Purified Cortrophin gel) - for Infantile Spasms, Multiple Sclerosis Exacerbations Open a PDF 09/13/2024
Showing 1– 25 of 71 Results

 

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