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– 74 of 74 Results
Title Last Updated
Lyfgenia (lovotibeglogene autotemcel) Drug Policy - Medical Benefit Open a PDF 03/06/2025
Lantidra (donislecel-jujn) - Medical Benefit (Commercial, Essential Plan, Medicaid Managed Care & Medicare) Open a PDF 03/06/2025
Intravenous Iron Replacement Products Policy - Medical Benefit Open a PDF 03/06/2025
Interleukin Antagonists for Asthma and Other Conditions - (Health Professional Administered) Medical Benefit & (Self-Administered) Rx Benefit - (Adbry, Cinqair, Dupixent, Ebglyss, Fasenra, Nemluvio, & Nucala) Open a PDF 03/06/2025
Infertility Medications Policy Open a PDF 03/06/2025
Hereditary Angioedema (HAE) For Berinert, Cinryze, Firazyr, Icatibant Haegarda, Kalbitor, Orladeyo, Ruconest, Sajazir, and Takhzyro Open a PDF 03/06/2025
Headache Disorder – (Aimovig (erenumab-aooe) (Rx), Ajovy (fremanezumab-vfrm) (Rx & Medical), dihydroergotamine 1 mg/mL ampule (Rx), Elyxyb (celecoxib oral solution) Rx, Emgality 120 mg (galcanezumab-gnlm) (Rx), Emgality 300 mg (galcanezumab-gnlm) (Rx), Ergomar (ergotamine tartrate) Rx, Migranal, dihydroergotamine 4 mg/mL nasal spray, 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 03/06/2025
Growth Hormone Policy Open a PDF 03/06/2025
Gamma-Aminobutyric Acid (GABA) A Receptor Positive Modulators for Postpartum Depression Open a PDF 03/06/2025
Enbrel (etanercept) – for Ankylosing Spondylitis, Juvenile Idiopathic Arthritis, Plaque Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis Open a PDF 03/06/2025
Elevidys (delandistrogene moxeparvovec-rokl) - Medical Benefit (Medicaid Managed Care, Essential Plan, Commercial, & Medicare) Open a PDF 03/06/2025
Duchenne Muscular Dystrophy (DMD) - Medical Benefit (Agamree, Amondys 45, Duvyzat, Emflaza and generic deflazacort, Exondys 51, Viltepso and Vyondys 53) Open a PDF 03/06/2025
Diabetic Incretin Mimetic Agents Policy Open a PDF 03/06/2025
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 03/06/2025
Casgevy (exagamglogene autotemcel) Drug Policy - Medical Benefit Open a PDF 03/06/2025
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 03/06/2025
Antihemophilic Agents for Medicaid Managed Care (MMC), Health and Recovery Program (HARP), and Dual Eligible Special Needs Plan (D-SNP) Open a PDF 03/06/2025
Anti-Amyloid Directed Therapies Policy - (Aduhelm, Kisunla, and Leqembi) - Medical Benefit Open a PDF 03/06/2025
Amyotrophic Lateral Sclerosis (ALS) Policy - (Qalsody, Radicava and Radicava ORS, Relyvrio, Teglutik & Tiglutik) - Medical & Rx Benefit Open a PDF 03/06/2025
Alpha-1 Antitrypsin Therapy (AAT) - Medical Benefit Open a PDF 03/06/2025
Attention Deficit Hyperactivity Disorder (ADHD) Policy - Adzenys ER, Adzenys XR ODT, Azstarys, Cotempla XR ODT, Desoxyn, Dyanavel XR, Jornay PM, Mydayis, Onyda XR, Qelbree, Quillichew ER, Quillivant, Xelstrym Open a PDF 03/06/2025
Patient Protection and Affordable Care Act (PPACA) - Preventive Items and Services Open a PDF 02/06/2025
Compounded Drug Products Policy Open a PDF 02/06/2025
Low Clinical Impact Drugs - Rx Open a PDF 01/01/2025
Showing 51– 74 of 74 Results

 

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