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 51– 75 of 81 Results
Title Last Updated
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 08/08/2025
Chimeric Antigen Receptor T Cell (CAR-T) Therapy – (Health Professional Administered) (Abecma, Aucatzyl, Breyanzi, Carvykti, Kymriah, Tecartus, & Yescarta) - Medical Benefit Open a PDF 07/07/2025
Testosterone Drug Policy (Testopel Aveed Azmiro) - Medical Benefit Open a PDF 07/01/2025
Intravenous Iron Replacement Products Policy - Medical Benefit Open a PDF 07/01/2025
Monoclonal Antibodies for the Treatment of Hemophilia – (Health Professional Administered) Medical Benefit & (Self-Administered) Rx Benefit - (Alhemo, Hemlibra, Hympavzi, Qfitlia) Open a PDF 06/25/2025
Elevidys (delandistrogene moxeparvovec-rokl) (Medicaid Managed Care, Essential Plan, Commercial, & Medicare) - Medical Benefit Open a PDF 06/24/2025
Parkinson’s Disease Drug Policy – (Self Administration) Rx Benefit & (Health Professional Administered) Medical Benefit - (Apokyn & apomorphine hydrochloride injection (Rx), Gocovri - amantadine ER capsules (Rx), Inbrija - levodopa inhalation (Rx), Mirapex ER and pramipexole ER (Rx), Neupro - rotigotine patch (Rx), Nourianz - istradefylline tablets (Rx), Nuplazid - pimavanserin tablets & capsules (Rx), Onapgo (apomorphine) (Rx & Medical), Osmolex - amantadine ER tablet (Rx), Rytary and Crexont - carbidopa/levodopa ER capsule (Rx), Zelapar ODT - Selegiline Hydrochloride (L-Deprenyl) tablet (Rx), Vyalev (foscarbidopa/foslevodopa injection) (Rx & Medical) Open a PDF 06/18/2025
Blood Modifiers - (Cosela, Fulphila, Fylnetra, Granix, Neupogen, Nivestym, Nypozi, Nyvepria, Releuko, Rolvedon, Ryzneuta, Stimufend, Ziextenzo) - Rx (Self Administration) & Medical Benefits (Health Professional Administered) Open a PDF 06/09/2025
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, Prolate Solution & Generic oxycodone-APAP 100-300mg/5ml, Prolate tablets, Nalocet, & generic oxycodone-APAP 5mg/300mg and oxycodone-APAP 10mg/300mg & oxycodone-APAP 2.5mg/300mg, and Roxybond Open a PDF 05/21/2025
Xolair (omalizumab) Drug Policy Open a PDF 05/08/2025
Rezdiffra (resmetirom) Drug Policy Open a PDF 05/08/2025
Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp) Open a PDF 05/08/2025
Off-Label Use of FDA Approved Drugs Open a PDF 05/08/2025
Remicade® (infliximab), Infliximab, Renflexis® (infliximab-abda), Avsola® (infliximab-axxq), Inflectra® (infliximab-dyyb) - (Health Professional Administered) - Medical Benefit Open a PDF 05/08/2025
Amyotrophic Lateral Sclerosis (ALS) Policy - (Qalsody, Radicava and Radicava ORS, Relyvrio, Teglutik & Tiglutik) - Medical & Rx Benefit Open a PDF 05/08/2025
Alpha-1 Antitrypsin Therapy (AAT) - Medical Benefit Open a PDF 05/08/2025
Ryoncil (remestemcel-l-rknd) Drug Policy - (Health Professional Administered) - Medical Benefit Open a PDF 05/08/2025
Hemophilia Gene Therapies Policy - (Beqvez, Hemgenix & Roctavian) - Medical Benefit Open a PDF 04/01/2025
Medicare Part D Formulary Level Cumulative Opioid and Opioid / Buprenorphine POS Edits Open a PDF 03/11/2025
Ohtuvayre (ensifentrine) Policy for Commercial, Exchange, & SafetyNet - Rx Benefit; Medicare Advantage & DSNP - Medical Benefit Open a PDF 03/07/2025
Non-Formulary Medication Exception Review Policy Open a PDF 03/06/2025
Spinal Muscular Atrophy (SMA) - Medical Benefit (Evrysdi (risdiplam), Spinraza (nusinersen), Zolgensma (onasemnogene abeparovec-xioi)) Open a PDF 03/06/2025
Repository Corticotropin Injection (Medical & Rx Benefit) (Acthar HP and Purified Cortrophin gel) - for Infantile Spasms, Multiple Sclerosis Exacerbations Open a PDF 03/06/2025
Qalsody (tofersen) Policy - Medical Benefit Open a PDF 03/06/2025
Ocaliva (obeticholic acid) Drug Policy - Medical Benefit Open a PDF 03/06/2025
Showing 51– 75 of 81 Results

 

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