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 64 Results
Title Last Updated
Amyotrophic Lateral Sclerosis (ALS) Policy - (Exservan, Qalsody, Radicava and Radicava ORS, Relyvrio, Teglutik, & Tiglutik) - Medical & Rx Benefit Open a PDF 04/12/2024
Xolair (omalizumab) Open a PDF 04/11/2024
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)) Open a PDF 04/11/2024
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), 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), 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 (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), Veopoz (Medical), Vijoice (Rx), Voxzogo (Rx), Vyjuvek (Medical), Vyvgart (Medical), Vyvgart Hytrulo (Medical), Zilbrysq (Rx), Zokinvy (Rx), Ztalmy (Rx), Zynteglo (Rx)) Open a PDF 04/11/2024
Osteoporosis - Evenity® (romosozumab-aqqg), Forteo® (teriparatide), Teriparatide, Prolia® (denosumab), Tymlos® (abaloparatide), Miacalcin injection®, calcitonin salmon injection Open a PDF 04/11/2024
Interleukin Antagonists for Asthma and Other Conditions: Nucala (mepolizumab), Cinqair (reslizumab), Fasenra (benralizumab), Dupixent (dupilumab), & Adbry (tralokinumab-ldrm) Open a PDF 04/11/2024
Step Therapy Drug Policy - Acyclovir 5% cream, Adapalene 0.1% (Lotion, Soln, Swab), Admelog, Adlarity, AirDuo Digihaler, AirDuo Respiclick, Alogliptin, Alogliptin/metformin, Alogliptin/pioglitazone, Alvesco, Amitiza, Amzeeq, Anzemet, Apidra, Armonair Digihaler, Aspart Insulin, Aczone 7.5%, Aubagio, Bafiertam, Belsomra, Blood Glucose Meters and Test Strips, Brexafemme, Budesonide/Formoterol, Caplyta, Clindagel 75 mL, Clindamycin 1% Gel 75 mL (Oceanside & Solaris), Dapagliflozin, Dapagliflozin/Metformin, Dapsone 7.5%, Dayvigo, Denavir 1% Cream, Dexilant, Dexlansoprazole DR, Differin 0.1% Lotion, Doryx, Doryx MPC, Doxycycline hyclate DR, Drizalma Sprinkle, Duaklir Pressair, Ecoza, Edarbi, Edarbyclor, Edluar, Emsam, Ertaczo, Estring, Eucrisa Ointment, Fanapt, Fiasp, Flovent Diskus and Flovent HFA, Fluticasone-Vilanterol, Fluticasone-salmeterol HFA, Forfivo XL 450mg, Fortamet, Gelnique, Glumetza, Ibsrela, Insulin Aspart, Invokamet, Invokamet XR, Invokana, Kazano, Latanoprost/PF, Latuda, Livalo, Lonhala Magnair 25 mcg Refill & Starter, Luliconazole, Luzu, Lyuzeh, Metformin ER (generics of Fortamet and Glumetza), Metformin HCl 625 mg, Motegrity, Naftifine, Naftin Gel, Nesina, Norgesic Forte, Noritate, Novolin 70-30, Novolin N, Novolin R, Novolog, Novolog Mix 70/30, Omeprazole/Sodium Bicarbonate Packets, Onzetra Spray, Orphenadrine/Aspirin/Caffeine, Orphengesic Forte, Oseni, Osphena, Oxistat Lotion, Oxytrol, Pancreaze, Penciclovir 1% Cream, Pertzye, Pheburane, Ponvory, Praluent, Prograf Granules, Pulmicort Flexhaler, Qtern, Quviviq, Rezvoglar, Relistor Tablet, Restasis 0.05%, Restasis Multidose 0.05%, Rexulti, Rhopressa, Rocklatan, Savaysa, Sancuso, Savaysa, Savella, Secuado, Segluromet, Sernivo Lotion, Spiriva, Steglatro, Symproic, Tafluprost, Thalitone, Tosymra, Tudorza Pressair, Ultravate Lotion, Venlafaxine ER Tablets, Verdeso, Vraylar, Vumerity, Vyzulta, Xadago, Xelpros, Xerese 5%-1% Cream, Xolegel, Yupelri, Zegerid Packets, Zembrace, Zerviate, Zilxi 1.5%, Zioptan, Zolmitriptan Nasal Spray, Zomig Nasal Spray, Zolpimist, Zovirax 5% cream, Zuplenz, Zyclara 2.5% Cream Pump, Zyclara 3.75% Cream, Zyclara 3.75% Cream Pump, Zypitamag) Open a PDF 04/09/2024
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 04/05/2024
Chimeric Antigen Receptor T Cell (CAR-T) Therapy – (Medical Benefit) (Health Professional Administered) - (Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, & Yescarta) Open a PDF 04/05/2024
Opioid Management Health and Safety Program- (Concurrent use of Opioid/Buprenorphine Products, Extended-release (long-acting) opioids, Morphine Milligram Equivalents (MME), Levorphanol, Opioid-naïve ADULT 7-day supply for first FOUR fills limit, Opioid-naïve PEDIATRIC 3-day supply for first FOUR fills limit, Opioid Cough & Cold medicines, Opioids drugs requiring Step Therapy, Oxaydo, Prolate Solution & Generic oxycodone-APAP 100-300mg/5ml, Prolate tablets, Primlev, Nalocet, & generic oxycodone-APAP 5mg/300mg and oxycodone-APAP 10mg/300mg & oxycodone-APAP 2.5mg/300mg, Roxybond, and Transmucosal Immediate-Release Fentanyl (TIRF) Medications) Open a PDF 04/05/2024
Blood Modifiers - (Cosela, Fulphila, Fylnetra, Granix, Neupogen, Nivestym, Nyvepria, Releuko, Rolvedon, Stimufend, Ziextenzo) - Rx (Self Administration) & Medical Benefits (Health Professional Administered) Open a PDF 04/02/2024
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Policy - (celecoxib tablets, Coxanto, Diclofenac solution, diclofenac capsules & patches, diclofenac potassium tablets, fenoprofen capsules & tablets, Fenortho, Flector, Ibuprofen/famotidine, Indocin, indomethacin capsules, indomethacin suppositories, ketoprofen capsules, ketorolac/tromethamine nasal spray, kiprofen, Licart, Lofena, meloxicam capsules, Meloxicam oral suspension, nabumetone tablets, Nalfon, Naprelan, Naprosyn suspension, naproxen/esomeprazole tablets, naproxen ER, naproxen suspension, oxaprozin capsules, Relafen DS, Seglentis, Sprix, Tivorbex, tramadol tablets, Vimovo, Vivlodex, Zipsor, & Zorvolex) Open a PDF 04/01/2024
Clinical Review Prior Authorization Rx (CRPA) Open a PDF 04/01/2024
Oncology CRPA (Medical Benefit) (Health Professional Administered) – (Abecma, Abraxane, Adcetris, Adstiladrin, Arzerra, Asparlas, Beleodaq, Belrapzo, Bendamustine HCL, Bendeka, Besponsa, Blincyto, Breyanzi, Camcevi, Carvykti, Colimvi, Cyramza, Danyelza, Darzalex., Darzalex Faspro, Elahere, Elitek, Elrexfio, Elzonris, Empliciti, Enhertu, Epkinly, Erwinaze, Folotyn, Fyarro, Gazyva, 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, Tecartus, Tivdak, Torisel, Temsirolimus, Trodelvy, Vectibix, Vivimusta, Vyxeos, Xgeva, Yescarta, Yondelis, Zaltrap, Zepzelca, & Zynlonta) Open a PDF 04/01/2024
Elevidys (delandistrogene moxeparvovec-rokl) - Medical Benefit - (Medicaid Managed Care, Essential Plan, Commercial, & Medicare) Open a PDF 04/01/2024
Duchenne Muscular Dystrophy (DMD) - Agamree, Amondys 45, Emflaza and generic deflazacort, Exondys 51, Viltepso and Vyondys 53 Open a PDF 04/01/2024
Gamma-Aminobutyric Acid (GABA) A Receptor Positive Modulators for Postpartum Depression Open a PDF 04/01/2024
Dual Special Needs Plan (D-SNP) 2024 Step Therapy Policy Open a PDF 03/29/2024
Dual Special Needs Plan (D-SNP) 2024 Prior Authorization Policy Open a PDF 03/29/2024
Medicare Part D 2024 Step Therapy Open a PDF 03/29/2024
Medicare Part D 2024 Prior Authorization Policy Open a PDF 03/29/2024
Immune Checkpoint Inhibitor (CPI) (Health Professional Administered) Medical Benefit - (Bavencio, Imfinzi, Imjudo, Jemperli, Keytruda, Libtayo, Loqtorzi, Opdivo, Opdualag, Tecentriq, Yervoy, and Zynyz) Open a PDF 03/21/2024
Quantity Limit Open a PDF 03/20/2024
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 03/15/2024
Antihemophilic Agents for Medicaid Managed Care (MMC), Health and Recovery Program (HARP), and Dual Eligible Special Needs Plan (D-SNP) Open a PDF 03/15/2024
Showing 26– 50 of 64 Results

 

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