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 75 Results
Title Last Updated
Lantidra (donislecel-jujn) - Medical Benefit (Commercial, Essential Plan, Medicaid Managed Care & Medicare) Open a PDF 09/13/2024
Intravenous Iron Replacement Products Policy - Medical Benefit Open a PDF 09/13/2024
Infertility Medications Policy Open a PDF 09/13/2024
Hereditary Angioedema (HAE) For Berinert, Cinryze, Firazyr, Icatibant Haegarda, Kalbitor, Orladeyo, Ruconest, Sajazir, and Takhzyro Open a PDF 09/13/2024
Hemophilia Gene Therapies Policy - (Beqvez, Hemgenix & Roctavian) - Medical Benefit Open a PDF 09/13/2024
Hemlibra (emicizumab-kxwh) Open a PDF 09/13/2024
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 09/13/2024
Geographic Atrophy Drug Policy (Health Professional Administered) - Medical Benefit (Izervay, Syfovre) Open a PDF 09/13/2024
Gamma-Aminobutyric Acid (GABA) A Receptor Positive Modulators for Postpartum Depression Open a PDF 09/13/2024
Diabetic Incretin Mimetic Agents Policy Open a PDF 09/13/2024
Compounded Drug Products Policy Open a PDF 09/13/2024
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 09/13/2024
Chimeric Antigen Receptor T Cell (CAR-T) Therapy – (Medical Benefit) (Health Professional Administered) - (Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, & Yescarta) Open a PDF 09/13/2024
Casgevy (exagamglogene autotemcel) Drug Policy - Medical Benefit Open a PDF 09/13/2024
Antihemophilic Agents for Medicaid Managed Care (MMC), Health and Recovery Program (HARP), and Dual Eligible Special Needs Plan (D-SNP) Open a PDF 09/13/2024
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 09/13/2024
Anti-Amyloid Directed Therapies Policy - (Aduhelm, Kisunla, and Leqembi) - Medical Benefit Open a PDF 09/13/2024
Blood Modifiers - (Cosela, Fulphila, Fylnetra, Granix, Neupogen, Nivestym, Nyvepria, Releuko, Rolvedon, Stimufend, Ziextenzo) - Rx (Self Administration) & Medical Benefits (Health Professional Administered) Open a PDF 09/18/2024
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, Lenmeldy, 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 09/19/2024
Sickle Cell Disease Management - Adakveo (crizanlizumab-tmca (Medical)), Endari (L-glutamine oral powder (Rx)), Siklos (hydroxyurea tablets (Rx)) Open a PDF 09/25/2024
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 10/01/2024
Cimzia (Certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis and Rheumatoid Arthritis Open a PDF 10/01/2024
Site of Care Redirection for Medical Specialty Drug Administration Policy Open a PDF 10/01/2024
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Policy - (celecoxib tablets, Coxanto, Diclofenac solution, diclofenac capsules & patches, diclofenac potassium tablets, dolobid 250mg 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 10/09/2024
Dual Special Needs Plan (D-SNP) 2025 Step Therapy Policy Open a PDF 10/14/2024
Showing 26– 50 of 75 Results

 

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