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 51– 70 of 70 Results
Title Last Updated
Elevidys (delandistrogene moxeparvovec-rokl) - Medical Benefit (Medicaid Managed Care, Essential Plan, Commercial, & Medicare) Open a PDF 06/20/2024
Casgevy (exagamglogene autotemcel) Drug Policy - Medical Benefit Open a PDF 06/20/2024
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 06/20/2024
Anti-Amyloid Directed Therapies Policy (Aduhelm (aducanumab-avwa) & Leqembi (lecanemab-irmb)) - Medical Benefit Open a PDF 06/20/2024
Alpha-1 Antitrypsin Therapy (AAT) - Medical Benefit Open a PDF 06/20/2024
Coronavirus (COVID-19) Impacted Drug Therapies (Lagevrio (molnupiravir), Paxlovid (nirmatrelvir/ritonavir), Stromectol (ivermectin)) Open a PDF 06/11/2024
Enbrel (etanercept) – for Ankylosing Spondylitis, Juvenile Idiopathic Arthritis, Plaque Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis Open a PDF 06/04/2024
Adalimumab (Self-Administered - Rx benefit) (Humira® [adalimumab], Abrilada™[adalimumab-afzb], Amjevita™ [adalimumab-atto], Cyltezo®/ adalimumab-adbm [adalimumab-adbm], Hadlima™ [adalimumab-bwwd], Hulio®/adalimumab-fkjp [adalimumab-fkjp], Hyrimoz®/adalimumab-adaz [adalimumab-adaz], Idacio®/ adalimumab-aacf [adalimumab-aacf], Simlandi® (adalimumab-ryvk), Yuflyma® [adalimumab-aaty], Yusimry™ [adalimumab-aqvh]) Open a PDF 06/04/2024
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, Daurismo, Disperz, Erivedge, Erleada, Exkivity, Fotivda, Fruzaqla, Gavreto, Gilotrif, Hemady, Ibrance, Iclusig, Idhifa, Imbruvica, Inlyta, Inqovi, Inrebic, Iressa, Iwilfin, Jakafi, Jaypirca, Kisqali and Kisqali Femara Co-Pack, Koselugo, Krazati, 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, Truqap, Tukysa, Turalio, Tykerb, Valchlor, Vanflyta, Venclexta, Verzenio, Vitrakvi, Vizimpro, Vonjo, Votrient, Welireg, Xalkori, Xermelo, Xospata, Xpovio Xtandi, Yonsa, Zejula, Zelboraf, Zolinza, Zydelig, Zykadia, Zytiga) Open a PDF 05/30/2024
Quantity Limit Open a PDF 05/20/2024
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, Tolectin 600mg tablets, tramadol tablets, Vimovo, Vivlodex, Zipsor, & Zorvolex) Open a PDF 05/14/2024
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 05/10/2024
Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp) Open a PDF 05/09/2024
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 05/09/2024
Growth Hormone Policy Open a PDF 05/09/2024
Weight Management - Contrave, Orlistat, Qsymia, Saxenda, Wegovy, Xenical, Zepbound Open a PDF 04/22/2024
Attention Deficit Hyperactivity Disorder (ADHD) Policy - Azstarys, dextroamphetamine/amphetamine ER capsule (generic Mydayis), Dyanavel XR, Mydayis and Xelstrym, Adzenys XR ODT (amphetamine ER ODT), Adzenys ER (and generic amphetamine ER suspension), Cotempla XR ODT (methylphenidate ER ODT), Dyanavel XR (amphetamine ER suspension), Quillichew ER (methylphenidate ER chewable tablets), Quillivant (methylphenidate ER suspension), Desoxyn and generic methamphetamine (Rx), Jornay PM (methylphenidate ER capsules), Qelbree (viloxazine ER capsules) Open a PDF 02/08/2024
Repository Corticotropin Injection (Medical & Rx Benefit) (Acthar HP and Purified Cortrophin gel) - for Infantile Spasms, Multiple Sclerosis Exacerbations Open a PDF 02/08/2024
Patient Protection and Affordable Care Act - Preventive Items and Services Open a PDF 02/08/2024
Compounded Drug Products Policy Open a PDF 02/08/2024
Showing 51– 70 of 70 Results

 

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