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
Spinal Muscular Atrophy (SMA) – Evrysdi (risdiplam), Spinraza (nusinersen), Zolgensma (onasemnogene abeparovec-xioi) Open a PDF 9/16/2021
Zulresso (brexanolone injection) for Postpartum Depression Open a PDF 8/9/2022
Anorexiants; Contrave (naltrexone/bupropion ER), Qsymia (phentermine/topiramate ER), Saxenda (liraglutide), Wegovy (semaglutide) and Xenical® (orlistat), Imcivree (setmelanotide) Open a PDF 8/9/2022
Aduhelm (aducanumab-avwa) Policy Open a PDF 8/9/2022
Stelera (Ustekinumab) – for Crohn’s Disease, Plaque Psoriasis and Psoriatic Arthritis Open a PDF 8/8/2022
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), Taltz – ixekizumab (Rx), Tremfya – guselkumab (Medical or Rx), Xeljanz and Xeljanz XR- tofacitinib and tofacitinib ER (Rx), Zeposia- ozanimod (Rx)) Open a PDF 8/8/2022
Inborn Errors of Metabolic Diseases (IEM) Open a PDF 8/4/2022
Interleukin Antagonists for Asthma and Other Conditions: Nucala (mepolizumab), Cinqair (reslizumab), Fasenra (benralizumab), & Dupixent (dupilumab) Open a PDF 8/15/2022
Rare Diseases 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), Mycapssa (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), Sandostatin LAR (Rx & Medical), 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 8/1/2022
Step Therapy Policy Open a PDF 7/28/2022
Clinical Review Prior Authorization Rx (CRPA) Open a PDF 7/20/2022
Quantity Limit Open a PDF 7/14/2022
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) (Duexis, fenoprofen tablets, Flector, Licart, Lofena, diclofenac patches, indomethacin capsules, indomethacin suppositories, ketoprofen capsules, Naprelan, naproxen ER, naproxen suspension, Pennsaid, Qmiiz, Relafen DS, Seglentis, Sprix, ketorolac/tromethamine nasal spray, Tivorbex, Vimovo, Vivlodex, meloxicam capsules, Zipsor, Zorvolex and diclofenac 35 mg capsules) Open a PDF 7/14/2022
Headache Disorders Open a PDF 7/14/2022
Oncology Clinical Review Prior Authorization Rx Open a PDF 7/11/2022
Oncology Clinical Review Prior Authorization (CRPA) Medical Open a PDF 7/11/2022
Non-Formulary Medication Exception Review Policy Open a PDF 7/11/2022
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
Viscosupplementation with Hyaluronic Acid Open a PDF 6/28/2022
Tezspire™ (tezepelumab-ekko subcutaneous injection) Open a PDF 6/28/2022
Pulmonary Hypertension (PH) Open a PDF 6/24/2022
Oncology Biosimilar Drug Policy Open a PDF 6/21/2022
Intravenous Immune Globulin (IVIG) & Sub-Cutaneous Immune Globulin (SCIG) Therapy Open a PDF 6/15/2022
Xolair (omalizumab) Open a PDF 5/5/2022
Showing 1– 25 of 56 Results
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