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.

As of April 1, 2023, members enrolled in Blue Choice Option, HMO Blue Option, and Blue Option Plus receive their prescription medications 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 79 Results
Title Last Updated
Tezspire™ (tezepelumab-ekko subcutaneous injection) Open a PDF 12/22/2025
Viscosupplementation with Hyaluronic Acid (Durolane, Euflexxa, Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Hymovis One, Monovisc, Orthovisc, Supartz, Synojoynt, Synvisc One, Triluron, TriVisc, Visco-3) (Health Professional Administered) – Medical Benefit Open a PDF 12/17/2025
Chimeric Antigen Receptor T Cell (CAR-T) Therapy – (Health Professional Administered) (Abecma, Aucatzyl, Breyanzi, Carvykti, Kymriah, Tecartus, & Yescarta) - Medical Benefit Open a PDF 12/05/2025
Hemophilia Gene Therapies Policy - (Hemgenix & Roctavian) - Medical Benefit Open a PDF 11/20/2025
Gamma-Aminobutyric Acid (GABA) A Receptor Positive Modulators for Postpartum Depression (Self-Administered) - Rx Benefit Open a PDF 11/20/2025
Duchenne Muscular Dystrophy (DMD) - (Agamree, Amondys 45, Duvyzat, Emflaza, Exondys 51, Viltepso and Vyondys 53) (Self-Administered) - Rx Benefit & (Health Professional Administered) - Medical Benefit Open a PDF 11/20/2025
Immune Checkpoint Inhibitor (CPI) (Health Professional Administered) - (Bavencio, Imfinzi, Imjudo, Jemperli, Keytruda, Keytruda Qlex, Libtayo, Loqtorzi, Opdivo, Optivo, Opdualag, Qvantig, Tecentriq, Tecentriq Hybreza, Tevimbra, Unloxcyt, Yervoy, and Zynyz) - Medical Benefit Open a PDF 11/19/2025
Xolair (omalizumab) Drug Policy Open a PDF 11/19/2025
Testosterone Drug Policy (Testopel Aveed Azmiro) - Medical Benefit Open a PDF 11/19/2025
Spinal Muscular Atrophy (SMA) - Medical Benefit (Evrysdi (risdiplam), Spinraza (nusinersen), Zolgensma (onasemnogene abeparovec-xioi)) Open a PDF 11/19/2025
Sickle Cell Disease Management - Adakveo (crizanlizumab-tmca (Medical)), Endari (L-glutamine oral powder (Rx)), Oxbryta (voxelotor (Rx) for 300 mg Tablets, 500mg Tablets and 300mg Tablets for Oral Suspension, Siklos (hydroxyurea tablets (Rx), Xromi (Rx)) Open a PDF 11/19/2025
Ryoncil (remestemcel-l-rknd) Drug Policy - (Health Professional Administered) - Medical Benefit Open a PDF 11/19/2025
Respiratory Syncytial Virus (RSV) Prophylaxis Drug Policy (Health Professional Administered) - Medical Benefit Open a PDF 11/19/2025
Repository Corticotropin Injection (Medical & Rx Benefit) (Acthar HP and Purified Cortrophin gel) - for Infantile Spasms, Multiple Sclerosis Exacerbations Open a PDF 11/19/2025
Osteoporosis Drug Policy – (Bildyos, Bonsity, calcitonin salmon injection, Conexxence, Evenity®, Forteo®, Jubbonti, Miacalcin injection®, Ospomyv, Prolia®, Stoboclo (denosumab-bmwo), Teriparatide, Tymlos®) Rx Benefit (Self-Administered) & Medical Benefit (Health Professional Administered) Open a PDF 11/19/2025
Ohtuvayre (ensifentrine) Policy for Commercial, Exchange, & SafetyNet - Rx Benefit; Medicare Advantage & DSNP - Medical Benefit Open a PDF 11/19/2025
Monoclonal Antibodies for the Treatment of Hemophilia – (Health Professional Administered) Medical Benefit & (Self-Administered) Rx Benefit - (Alhemo, Hemlibra, Hympavzi, Qfitlia) Open a PDF 11/19/2025
Kebilidi (eladocagene exuparvovec-tneq) (Health Professional Administered) - Medical Benefit Open a PDF 11/19/2025
Intravenous Iron Replacement Products Policy - Medical Benefit Open a PDF 11/19/2025
Intravenous Immune Globulin (IVIG) & Sub-Cutaneous Immune Globulin (SCIG) Therapy (Alyglo, Asceniv, Bivigam, Cutaquig, Cuvitru, Flebogamma, Gammagard Liquid, Gammagard S/D powder, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, & Xembify) (Self-Administered) - Rx Benefit & (Health Professional Administered) - Medical Benefit Open a PDF 11/19/2025
Interleukin Antagonists for Asthma and Other Conditions - (Health Professional Administered) Medical Benefit & (Self-Administered) Rx Benefit - (Adbry, Bullous Pemphigoid, Cinqair, Dupixent, Ebglyss, Fasenra, Nemluvio, & Nucala) Open a PDF 11/19/2025
Remicade® (infliximab), Infliximab, Renflexis® (infliximab-abda), Avsola® (infliximab-axxq), Inflectra® (infliximab-dyyb) - (Health Professional Administered) - Medical Benefit Open a PDF 11/19/2025
Inborn Errors of Metabolism Policy (Rx & Medical Benefit) – (Attruby, Amvuttra, Brineura, Carbaglu and generic carglumic acid, Cerdelga, Cerezyme, Cholbam, Crysvita, Ctexli, Dojolvi, Elaprase, Elelyso, Elfabrio, Fabrazyme, Galafold, Givlaari, Harliku, Javygtor and generic sapropterin, Kanuma, Kuvan, Lamzede, Lumizyme, Mepsevii , Naglazyme, Nexviazyme, nitisinone capsule, Nityr, Nulibry, Olpruva, Onpattro, Orfadin, Oxlumo, Palynziq, Pombiliti, Ravicti , Rivfloza, Strensiq, Sucraid, Tegsedi, Vimizim, VPRIV, Vyndaqel, Vyndamax, Wainua, Xenpozyme, Xuriden, Yargesa & Zavesca) Open a PDF 11/19/2025
Elevidys (delandistrogene moxeparvovec-rokl) (Medicaid Managed Care, Essential Plan, Commercial, & Medicare) - Medical Benefit Open a PDF 11/19/2025
Botulinum Toxin (Botox, Daxxify, Dysport, Myobloc, Xeomin) – for Medicaid Managed Care (MMC), Health and Recovery Program (HARP), Child Health Plus (CHP), Essential Plan (EP), Exchange Plans, Commercial, and Dual Eligible Special Needs Plan (D-SNP) - Medical Benefit Open a PDF 11/19/2025
Showing 1– 25 of 79 Results

 

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