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
Gamma-Aminobutyric Acid (GABA) A Receptor Positive Modulators for Postpartum Depression Open a PDF 06/20/2024
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
Xolair (omalizumab) Drug Policy Open a PDF 06/24/2024
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
Respiratory Syncytial Virus (RSV) Prophylaxis - Medical Benefit Open a PDF 06/25/2024
Remicade® (infliximab), Infliximab, Renflexis® (infliximab-abda) - Medical Benefit Open a PDF 06/28/2024
Dual Special Needs Plan (D-SNP) 2024 Prior Authorization Policy Open a PDF 06/28/2024
Dual Special Needs Plan (D-SNP) 2024 Step Therapy Policy Open a PDF 06/28/2024
Medicare Part D 2024 Prior Authorization Policy Open a PDF 06/28/2024
Showing 26– 50 of 70 Results

 

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