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 26– 50 of 72 Results
Title Last Updated
Dual Special Needs Plan (D-SNP) 2025 Step Therapy Policy Open a PDF 10/14/2024
Dual Special Needs Plan (D-SNP) 2025 Prior Authorization Policy Open a PDF 10/14/2024
Off-Label Use of FDA Approved Drugs Open a PDF 09/06/2024
Patient Protection and Affordable Care Act (PPACA) - Preventive Items and Services Open a PDF 09/02/2024
Generic Advantage Program / MAC Penalty Open a PDF 07/10/2023
Ohtuvayre (ensifentrine) Policy for Commercial, Exchange, & SafetyNet - Rx Benefit; Medicare Advantage & DSNP - Medical Benefit Open a PDF 02/07/2025
Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs - Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs - (Actemra - tocilizumab (Medical or Rx), Bimzelx, Cibinqo - abrocitinib (Rx), Cosentyx - secukinumab (Rx), 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 02/06/2025
Oncology CRPA (Rx Benefit) (Self-Administration) - (Abiraterone 500 mg tablet, Afinitor, Akeega, Alecensa, Alunbrig, Augtyro, Ayvakit, Balversa, Besremi, (NOTE: both Rx and Medical benefit drug), Bosulif, Braftovi, Brukinsa, Cabometyx, Calquence, Caprelsa, Cometriq, Copiktra, Cotellic, Dasatinib, Daurismo, Disperz, Erivedge, Erleada, Exkivity, Fotivda, Fruzaqla, Gavreto, Gilotrif, Hemady, Ibrance, Iclusig, Idhifa, Imbruvica, Imkeldi, Inlyta, Inqovi, Inrebic, Iressa, Iwilfin, Jakafi, Jaypirca, Kisqali and Kisqali Femara Co-Pack, Koselugo, Krazati, Lazcluze, Lenvima, Lonsurf, Lorbrena, Lumakras, Lynparza tablets, Lytgobi, Mekinist, Mektovi, Nerlynx, Nexavar, Ninlaro, Nubeqa, Odomzo, Ogsiveo, Ojemda, Ojjaara, Onureg, Orgovyx, Orserdu, Pemazyre, Piqray, Pomalyst, Purixan, Qinlock, Retevmo, Revlimid, Rezlidhia Rezurock, Rozlytrek, Rubraca, Rydapt, Scemblix, Soltamox, Sprycel, Stivarga, Sutent, Tabrecta, Tafinlar, Tagrisso, Talzenna, Tarceva, Targretin capsules, Targretin gel, Tasigna, Tazverik, Tepmetko, Tibsovo, Torpenz, Truqap, Tukysa, Turalio, Tykerb, Valchlor, Vanflyta, Venclexta, Verzenio, Vitrakvi, Vizimpro, Vonjo, Voranigo, Votrient, Welireg, Xalkori, Xermelo, Xospata, Xpovio Xtandi, Yonsa, Zejula, Zelboraf, Zolinza, Zydelig, Zykadia, Zytiga) Open a PDF 02/03/2025
Oncology CRPA - Medical Benefit (Health Professional Administered) – (Abecma, Abraxane, Adcetris, Adstiladrin, Amtagvi, Anktiva, Arzerra, Asparlas, Axtle, Beleodaq, Belrapzo, Bendamustine HCL, Bendeka, Besponsa, Bizengri, Blincyto, Boruzu, 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, Posfrea, Poteligeo, Pralatrexate, Provenge, Romidepsin, Rybrevant, Rylaze, Rytelo, Sarclisa, Talvey, Tecartus, Tecelra, Tecvayli, Temsirolimus, Tivdak, Torisel, Treanda, Trodelvy, Vectibix, Vivimusta, Vyloy, Vyxeos, Xgeva, Yescarta, Yondelis, Zaltrap, Zepzelca, Ziihera, & Zynlonta) Open a PDF 02/03/2025
Oncology Biosimilar Drug Policy - (Avastin (bevacizumab) and Alymsys (bevacizumab-maly), Herceptin (trastuzumab), Herceptin Hylecta (trastuzumab and hyaluronidase-oysk), Hercessi (trastuzumab-strf), Ogivri (trastuzumab-dkst), Ontruzant (trastuzumab-dttb), and Herzuma (trastuzumab-pkrb), Rituxan (rituximab), Rituxan Hycela (rituximab hyaluronidase), Riabni (rituximab-arrx) and Vegzelma (bevacizumab-adcd)) – Medical Benefit Open a PDF 02/03/2025
Immune Checkpoint Inhibitor (CPI) (Medical Benefit) (Health Professional Administered) - (Bavencio, Imfinzi, Imjudo, Jemperli, Keytruda, Libtayo, Loqtorzi, Opdivo, Optivo Qvantig, Opdualag, Tecentriq, Tecentriq Hybreza, Tevimbra, Yervoy, and Zynyz) Open a PDF 02/03/2025
Chimeric Antigen Receptor T Cell (CAR-T) Therapy – (Medical Benefit) (Health Professional Administered) - (Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, & Yescarta) Open a PDF 02/03/2025
Clinical Review Prior Authorization (CRPA) Policy - Medical Benefit for (Medicaid Managed Care, HARP, Essential Plan & Dual Special Needs Plan) - Benlysta IV (Medical), (Briumvi (Medical), Cablivi (Rx & Medical), Ceprotin (Medical), Eylea (Medical), Eylea HD (Medical), Gonadotropin-releasing hormone (GnRH) Analogs, Hydroxyprogesterone Caproate Injection (Medical), Krystexxa (Medical), Lemtrada (Medical), Leqvio (Medical), NPlate (Medical), Ocrevus (Medical), Pavblu (Medical), Pemgarda (Medical), Ranibizumab (Medical), Rebyota (Medical), Saphnelo (Medical), Spravato (Medical), Tysabri (Medical), Vabysmo (Medical), Zilretta (Medical), & Zoladex (Medical)) Open a PDF 02/01/2025
Site of Care Redirection for Medical Specialty Drug Administration Policy Open a PDF 02/01/2025
Clinical Review Prior Authorization (CRPA) Rx Drug Policy Open a PDF 02/01/2025
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 02/01/2025
Medicare Part B Step Therapy Drug List Open a PDF 02/01/2025
Elevidys (delandistrogene moxeparvovec-rokl) - Medical Benefit (Medicaid Managed Care, Essential Plan, Commercial, & Medicare) Open a PDF 01/31/2025
Weight Related Comorbidities Policy - Overweight Obesity Cardiovascular Disease- Contrave, Orlistat, Qsymia, Saxenda, Wegovy, Xenical, Zepbound Open a PDF 01/31/2025
Low Clinical Impact for Rx Drugs Policy Open a PDF 01/31/2025
Rare Diseases CRPA Policy (Medical and Rx Benefits) - (Actimmune (Medical & Rx), Adzynma (Medical), Aldurazyme (Medical), Arcalyst (Rx), Bylvay (Rx), Camzyos (Rx), Cuprimine and generic penicillamine capsules (Rx), Cuvrior (Rx), Daybue (Rx), Empaveli (Rx), Enjaymo (Medical), Enspryng (Rx or Medical), Evkeeza (Medical), Fabhalta (Rx), Filspari (Rx), Firdapse (Rx), Gamifant (Medical), Hyftor 0.2% gel (Rx), Ilaris (Medical), Imcivree (Rx), Increlex (Rx), Isturisa (Rx), Joenja (Rx), Juxtapid (Rx), Keveyis (Rx), Korlym (Rx), Lanreotide Acetate Injection (Medical & Rx), Livmarli (Rx), Luxturna (Medical), Myalept (Rx), Mycapssa (Rx), Ormalvi (Rx), Piasky (Medical), Procysbi (Rx), Pyrukynd (Rx), Reblozyl (Medical), Recombinant (Rx), Recorlev (Rx), Rethymic (Medical), Revcovi - (Medical & Rx), rh-IGF-1 (Rx), Ruzurgi (Rx), Ryplazim (Medical & Rx), Rystiggo (Medical), Sandostatin LAR and octreotide intramuscular injection (Rx & Medical), Scenesse (Medical), Signifor LAR (Medical), Signifor SC (Rx), Skyclarys (Rx), Skysona (Medical), Sohonos (Rx), Soliris (Medical), Somavert (Rx), Sylvant (Medical), Syprine, generic trientine capsules (Rx), Tarpeyo (Rx), Tavneos (Rx), Tepezza (Medical), Thiola, Thiola EC, and generic tiopronin (Rx), Tzield (Medical), Ultomiris (Medical), Uplizna (Medical), Venxxiva (Rx), Veopoz (Medical), Vijoice (Rx), Voxzogo (Rx), Voydeya (Rx), Vyjuvek (Medical), Vyvgart (Medical), Vyvgart Hytrulo (Medical), Xolremdi (Rx), Zilbrysq (Rx), Zokinvy (Rx), Ztalmy (Rx), Zynteglo (Rx)) Open a PDF 01/30/2025
Sickle Cell Disease Management - Adakveo (crizanlizumab-tmca (Medical)), Endari (L-glutamine oral powder (Rx)), Siklos (hydroxyurea tablets (Rx)) Open a PDF 01/28/2025
Compounded Drug Products Policy Open a PDF 01/22/2025
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 01/16/2025
Qalsody (tofersen) Policy - Medical Benefit Open a PDF 01/16/2025
Showing 26– 50 of 72 Results

 

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