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 70 Results
Title Last Updated
Infertility Medications Open a PDF 12/06/2023
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 12/06/2023
Medicare Part D Formulary Level Cumulative Opioid and Opioid / Buprenorphine POS Edits Open a PDF 11/30/2023
Non-Formulary Medication Exception Review Policy Open a PDF 11/30/2023
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), Tyenne Actemra biosimilar), Xeljanz and Xeljanz XR- tofacitinib and tofacitinib ER (Rx), Zeposia- ozanimod (Rx)) Open a PDF 07/12/2024
Site of Care Redirection for Medical Specialty Drug Administration Policy Open a PDF 07/12/2024
Medicare Part B Step Therapy Drug List Open a PDF 07/10/2024
Generic Advantage Program / MAC Penalty Open a PDF 07/10/2023
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
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
Duchenne Muscular Dystrophy (DMD) - Medical Benefit (Agamree, Amondys 45, Emflaza and generic deflazacort, Exondys 51, Viltepso and Vyondys 53) Open a PDF 07/02/2024
Clinical Review Prior Authorization Rx (CRPA) Open a PDF 07/01/2024
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 HD (Medical), Gonadotropin-releasing hormone (GnRH) Analogs, Hydroxyprogesterone Caproate Injection (Medical), Krystexxa (Medical), Lemtrada (Medical), Leqvio (Medical), NPlate (Medical), Ocrevus (Medical), Ranibizumab (Medical), Rebyota (Medical), Saphnelo (Medical), Spravato (Medical), Sunlenca (Rx & Medical), Trogarzo (Medical), Tysabri (Medical), Vabysmo (Medical), Zilretta (Medical), Zoladex (Medical) Open a PDF 07/01/2024
Lyfgenia (lovotibeglogene autotemcel) Drug Policy - Medical Benefit Open a PDF 07/01/2024
Rare Diseases (CRPA) Rx Benefits (Self-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, Increlex, Isturisa, Joenja, Juxtapid, Keveyis, Lanreotide Acetate Injection, Livmarli, Myalept, Mycapssa, Ormalvi, 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 07/01/2024
Oncology CRPA - Medical Benefit (Health Professional Administered) – (Abecma, Abraxane, Adcetris, Adstiladrin, Amtagvi, Anktiva, Arzerra, Asparlas, Beleodaq, Belrapzo, Bendamustine HCL, Bendeka, Besponsa, Blincyto, Breyanzi, Camcevi, Carvykti, Colimvi, Cyramza, Danyelza, Darzalex., Darzalex Docivyx, Faspro, Elahere, Elitek, Elrexfio, Elzonris, Empliciti, Enhertu, Epkinly, Erwinaze, Folotyn, Fyarro, Gazyva, Hepzato Kit, Imdelltra, Infugem, Istodax, Jelmyto, Kadcyla, Kimmtrak, Kymriah, Kyprolis, Lartruvo, Leuprolide Acetate Depot, Lumoxiti, Lunsumio, Margenza, Monjuvi, Mylotarg, Omisirge, Oncaspar, Onivyde, Paclitaxel protein-bound particles, Padcev, Pedmark, Pemfexy, Pemrydi, Phesgo, Polivy, Portrazza, Poteligeo, Pralatrexate, Provenge, Romidepsin, Rybrevant, Rylaze, Sarclisa, Talvey, Tecartus, Tecvayli, Temsirolimus, Tivdak, Torisel, Treanda, Trodelvy, Vectibix, Vivimusta, Vyxeos, Xgeva, Yescarta, Yondelis, Zaltrap, Zepzelca, & Zynlonta) Open a PDF 07/01/2024
Geographic Atrophy Drug Policy (Health Professional Administered) - Medical Benefit (Izervay, Syfovre) Open a PDF 07/01/2024
Remicade® (infliximab), Infliximab, Renflexis® (infliximab-abda) - Medical Benefit Open a PDF 06/28/2024
Dual Special Needs Plan (D-SNP) 2024 Prior Authorization Policy Open a PDF 06/28/2024
Dual Special Needs Plan (D-SNP) 2024 Step Therapy Policy Open a PDF 06/28/2024
Medicare Part D 2024 Prior Authorization Policy Open a PDF 06/28/2024
Diabetic Incretin Mimetic Agents Policy Open a PDF 06/28/2024
Medicare Part D 2024 Step Therapy Open a PDF 06/28/2024
Respiratory Syncytial Virus (RSV) Prophylaxis - Medical Benefit Open a PDF 06/25/2024
Xolair (omalizumab) Drug Policy Open a PDF 06/24/2024
Showing 1– 25 of 70 Results

 

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