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 70 Results
Title Last Updated
Tezspire™ (tezepelumab-ekko subcutaneous injection) Open a PDF 06/24/2024
Stelara (ustekinumab) – for Crohn’s Disease, Plaque Psoriasis and Psoriatic Arthritis Open a PDF 06/24/2024
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 06/24/2024
Off Label Use Open a PDF 06/24/2024
Inborn Errors of Metabolism Policy (Rx & Medical Benefit) – (Amvuttra, Brineura, Carbaglu and generic carglumic acid, Cerdelga, Cerezyme, Cholbam, Crysvita, Dojolvi, Elaprase, Elelyso, Elfabrio, Fabrazyme, Galafold, Givlaari, 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 06/24/2024
Hereditary Angioedema (HAE) For Berinert, Cinryze, Firazyr, Icatibant Haegarda, Kalbitor, Orladeyo, Ruconest, Sajazir, and Takhzyro Open a PDF 06/24/2024
Hemlibra (emicizumab-kxwh) Open a PDF 06/24/2024
Headache Disorder – (Aimovig (erenumab-aooe) (Rx), Ajovy (fremanezumab-vfrm) (Rx & Medical), D.H.E 45, dihydroergotamine 1 mg/mL ampule (Rx), Emgality 120 mg (galcanezumab-gnlm) (Rx), Emgality 300 mg (galcanezumab-gnlm) (Rx), Migranal, dihydroergotamine 4 mg/mL nasal spray, Trudhesa (Rx), Nurtec ODT (rimegepant) (Rx), Qulipta (atogepant) (Rx), Reyvow (lasmiditan) (Rx), Ubrelvy (ubrogepant) (Rx), Vyepti (eptinezumab-jjmr) (Medical), Zavzpret (zavegepant) (Rx) & Quantity Limit Criteria for Ubrelvy, Nurtec ODT, Reyvow, and Zavzpret) Open a PDF 06/24/2024
Cimzia (Certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis and Rheumatoid Arthritis Open a PDF 06/24/2024
Blood Modifiers - (Cosela, Fulphila, Fylnetra, Granix, Neupogen, Nivestym, Nyvepria, Releuko, Rolvedon, Stimufend, Ziextenzo) - Rx (Self Administration) & Medical Benefits (Health Professional Administered) Open a PDF 06/24/2024
Antihemophilic Agents for Medicaid Managed Care (MMC), Health and Recovery Program (HARP), and Dual Eligible Special Needs Plan (D-SNP) Open a PDF 06/24/2024
Amyotrophic Lateral Sclerosis (ALS) Policy - (Exservan, Qalsody, Radicava and Radicava ORS, Relyvrio, Teglutik, & Tiglutik) - Medical & Rx Benefit Open a PDF 06/24/2024
Chimeric Antigen Receptor T Cell (CAR-T) Therapy – (Medical Benefit) (Health Professional Administered) - (Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, & Yescarta) Open a PDF 06/24/2024
Intravenous Iron Replacement Products Policy - Medical Benefit Open a PDF 06/20/2024
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 06/20/2024
Xiaflex - Medical Benefit (collagenase clostridium histolyticum) Policy Open a PDF 06/20/2024
Viscosupplementation with Hyaluronic Acid - Medical Benefit (Durolane, Euflexxa, Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz, Synojoynt, Synvisc One, Triluron, TriVisc, Visco-3) Open a PDF 06/20/2024
Spinal Muscular Atrophy (SMA) - Medical Benefit (Evrysdi (risdiplam), Spinraza (nusinersen), Zolgensma (onasemnogene abeparovec-xioi)) Open a PDF 06/20/2024
Qalsody (tofersen) Policy - Medical Benefit Open a PDF 06/20/2024
Osteoporosis - Medical Benefit (Evenity® (romosozumab-aqqg), Forteo® (teriparatide), Teriparatide, Prolia® (denosumab), Tymlos® (abaloparatide), Miacalcin injection®, calcitonin salmon injection) Open a PDF 06/20/2024
Oncology Biosimilar Drug Policy - Medical Benefit (Avastin (bevacizumab) and Alymsys (bevacizumab-maly), Herceptin (trastuzumab), Herceptin Hylecta (trastuzumab and hyaluronidase-oysk), Ogivri (trastuzumab-dkst), Ontruzant (trastuzumab-dttb), and Herzuma (trastuzumab-pkrb), Rituxan (rituximab), Rituxan Hycela (rituximab hyaluronidase), Riabni (rituximab-arrx) and Vegzelma (bevacizumab-adcd)) Open a PDF 06/20/2024
Lantidra (donislecel-jujn) - Medical Benefit (Commercial, Essential Plan, Medicaid Managed Care & Medicare) Open a PDF 06/20/2024
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 06/20/2024
Hemophilia Gene Therapies Policy - Medical Benefits (Hemgenix & Roctavian) Open a PDF 06/20/2024
Gamma-Aminobutyric Acid (GABA) A Receptor Positive Modulators for Postpartum Depression Open a PDF 06/20/2024
Showing 26– 50 of 70 Results

 

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