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 1– 25 of 64 Results
Title Last Updated
Diabetic Incretin Mimetic Agents Policy Open a PDF 01/01/2024
Spinal Muscular Atrophy (SMA) – Evrysdi (risdiplam), Spinraza (nusinersen), Zolgensma (onasemnogene abeparovec-xioi) Open a PDF 01/11/2024
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
Tezspire™ (tezepelumab-ekko subcutaneous injection) 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
Oncology Biosimilar Drug Policy - (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) (Medical)) Open a PDF 02/08/2024
Growth Hormone Policy Open a PDF 02/08/2024
Coronavirus (COVID-19) Impacted Drug Therapies (Hydroxychloroquine, Lagevrio (molnupiravir), Paxlovid (nirmatrelvir/ritonavir), Stromectol (ivermectin)) Open a PDF 02/08/2024
Compounded Drug Products Policy Open a PDF 02/08/2024
Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp) Open a PDF 03/05/2024
Oncology Clinical Review Prior Authorization 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, 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 03/11/2024
Hemophilia Gene Therapies Policy (Medical Benefits) – (Hemgenix & Roctavian) Open a PDF 03/13/2024
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 03/13/2024
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
Quantity Limit Open a PDF 03/20/2024
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 03/21/2024
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
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
Showing 1– 25 of 64 Results

 

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