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 57 Results
Title Last Updated
Zulresso (brexanolone injection) for Postpartum Depression Open a PDF 3/15/2023
Xolair (omalizumab) Open a PDF 5/11/2023
Weight Management - Contrave, Orlistat, Qsymia, Saxenda, Wegovy, Xenical Open a PDF 5/24/2023
Viscosupplementation with Hyaluronic Acid Open a PDF 3/20/2023
Tezspire™ (tezepelumab-ekko subcutaneous injection) Open a PDF 5/1/2023
Synagis® (Palivizumab): Respiratory Syncytial Virus (RSV) Prophylaxis Open a PDF 11/17/2022
Step Therapy Drug Policy - Acyclovir 5% cream, Adapalene 0.1% (Lotion, Soln, Swab), Adlyxin, Admelog, Adlarity, AirDuo Digihaler, AirDuo Respiclick, Alogliptin, Alogliptin/metformin, Alogliptin/pioglitazone, Alvesco, Amitiza, Amzeeq, Anzemet, Apidra, Armonair Digihaler, Aspart Insulin, Atripla, Aczone 7.5%, Aubagio, Bafiertam, Belsomra, Blood Glucose Meters and Test Strips, Brexafemme, Breztri, Budesonide/Formoterol, Bydureon, Byetta, Caplyta, Clindagel 75 mL, Clindamycin 1% Gel 75 mL (Oceanside & Solaris), Daliresp, Dapsone 7.5%, Dayvigo, Denavir 1% Cream, Dexilant, Dexlansoprazole DR, Differin 0.1% Lotion, Doryx, Doxycycline hyclate DR, Drizalma Sprinkle, Duaklir Pressair, Ecoza, Edarbi, Edarbyclor, Edluar, Emsam, Ertaczo, Estring, Eucrisa Ointment, Fanapt, Fiasp, Fluticasone Propionate HFA, Fluticasone-Vilanterol, Fluticasone-salmeterol HFA, Forfivo XL 450mg, Fortamet, Gelnique, Gemtesa, Glumetza, Ibsrela, Kazano, Kombiglyze, Konvomep, Latuda, Livalo, Lonhala Magnair 25 mcg Refill & Starter, Luliconazole, Luzu, Metformin ER (generics of Fortamet and Glumetza), Metformin HCl 625 mg, Motegrity, Naftin Gel, Nesina, Norgesic Forte, Noritate, Novolog Mix 70/30, Omeprazole/Sodium Bicarbonate Packets, Onglyza, Onzetra Spray, Orphenadrine/Aspirin/Caffeine, Orphengesic Forte, Oseni, Osphena, Oxistat Lotion, Oxytrol, Ozempic, Pancreaze, Penciclovir 1% Cream, Pertzye, Ponvory, Praluent, Prograf Granules, Pulmicort Flexhaler, Qtern, Quviviq, Rezvoglar, Relistor Tablet, Restasis 0.05%, Restasis Multidose 0.05%, Rexulti, Rhopressa, Rocklatan, Roflumilast, Rybelsus, Savaysa, Sancuso, Savella, Secuado, Sernivo Lotion, Symproic, Tafluprost, Thalitone, Tosymra, Trulicity, Tudorza Pressair, Ultravate Lotion, Veltassa, Venlafaxine ER Tablets, Verdeso, Victoza, Vraylar, Vumerity, Vyzulta, Xadago, Xelpros, Xerese 5%-1% Cream, Xolegel, Yupelri, Zegerid Packets, Zembrace, Zerviate, Zilxi 1.5%, Zioptan, Zolmitriptan Nasal Spray, Zomig Nasal Spray, Zolpimist, Zovirax 5% cream, Zuplenz, Zypitamag Open a PDF 04/24/2023
Stelara (ustekinumab) – for Crohn’s Disease, Plaque Psoriasis and Psoriatic Arthritis Open a PDF 4/1/2023
Spinal Muscular Atrophy (SMA) – Evrysdi (risdiplam), Spinraza (nusinersen), Zolgensma (onasemnogene abeparovec-xioi) Open a PDF 4/28/2023
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 3/15/2023
Repository Corticotropin Injection (Acthar HP and Purified Cortrophin gel) - for Infantile Spasms, Multiple Sclerosis Exacerbations Open a PDF 4/1/2023
Remicade® (infliximab), Infliximab, Renflexis® (infliximab-abda) Open a PDF 3/15/2023
Rare Diseases CRPA Policy - (Actimmune - Interferon Gamma - 1B (Medical & Rx), Aldurazyme - laronidase (Medical), Arcalyst - rilonacept (Rx), Bylvay - odevixibat (Rx), Camzyos - mavacamten capsules (Rx), Cuprimine and generic penicillamine capsules (Rx), Cuvrior - trientine (Rx), Daybue - trofinetide (Rx)Empaveli - pegcetacoplan (Medical & Rx), Enjaymo - sutimlimab-jome (Medical), Enspryng - satralizumab-mwge injection (Rx or Medical), Evkeeza - evinacumab-dgnb (Medical), Filspari - sparsentan (Rx), Firdapse - amifampridine (Rx), Gamifant - emapalumab-lzsg (Medical), Hyftor 0.2% gel - sirolimus topical gel (Rx), Ilaris - canakinumab (Medical), Increlex - mecasermin, Isturisa - osilodrostat tablets (Rx), Joenja – leniolisib (Rx), Juxtapid - lomitapide capsules (Rx), Keveyis - dichlorphenamide (Rx), Korlym - mifepristone tablets (Rx), Lanreotide Acetate Injection (Medical & Rx), Livmarli - maralixibat (Rx), Luxturna - voretigene neparvovec-rzyl (Medical), Myalept - metreleptin (Rx), Mycapssa octreotide acetate (Rx), Procysbi - cysteamine capsules and packets (Rx), Pyrukynd - mitapivat tablets (Rx), Reblozyl -luspatercept-aamt (Medical), Recorlev - levoketoconazole (Rx), Rethymic - allogeneic processed thymus tissue-agdc (Medical), Revcovi - elapegademase-lvlr (Medical & Rx), Ruzurgi - amifampridine (Rx), Ryplazim - plasminogen, human-tvm (Medical & Rx), Sandostatin LAR (Rx & Medical), Scenesse - afamelanotide (Medical), Signifor LAR - pasireotide (Medical), Signifor SC - pasireotide solution (Rx), Skyclarys - omaveloxolone (Rx), Skysona-elivaldogene autotemcel (Medical), Soliris - eculizumab (Medical), Somavert - pegvisomant (Rx), Sylvant - siltuximab (Medical), Syprine, generic trientine capsules (Rx), Tarpeyo - budesonide delayed release capsules (Rx), Tavneos - avacopan (Rx), Tepezza - teprotumumab-trbw (Medical), Thiola, Thiola EC and generic tiopronin (Rx), Ultomiris - ravulizumab-cwvz injection (Medical), Uplizna - inebilizumab-cdon (Medical), Vijoice - alpelisib (Rx), Voxzogo - vosoritide (Rx), Vyvgart - efgartigimod alfa-fcab (Medical), Zokinvy - lonafarnib (Rx), Ztalmy -ganaxolone (Rx), Zynteglo - betibeglogene (Rx)) Open a PDF 5/30/2023
Quantity Limit Open a PDF 5/12/2023
Pulmonary Hypertension (PH) - Adcirca (tadalafil (including Alyq)(Rx)), Adempas (riociguat (Rx)), Flolan, Veletri, (epoprostenol (Medical)), Letairis (ambrisentan (Rx)), Opsumit (macitentan (Rx)), Orenitram (treprostinil (Rx)), Remodulin (treprostinil (Medical)), Revatio (sildenafil (Rx)), Tracleer (bosentan (Rx)), Tyvaso (treprostinil) inhalation, Tyvaso DPI (Rx)), Uptravi (selexipag) Rx)), Ventavis (iloprost) inhalation (Medical)), & Combination Therapy (Ambrisentan and tadalafil) Open a PDF 5/11/2023
Patient Protection and Affordable Care Act - Preventive Items and Services Open a PDF 04/01/2023
Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp) Open a PDF 5/11/2023
Osteoporosis - Evenity® (romosozumab-aqqg), Forteo® (teriparatide), Teriparatide, Prolia® (denosumab), Tymlos® (abaloparatide), Miacalcin injection®, calcitonin salmon injection Open a PDF 3/20/2023
Opioid Management Health & Safety Program Open a PDF 5/11/2023
Oncology Clinical Review Prior Authorization Rx - (Abiraterone 500 mg tablet, Afinitor (everolimus), Disperz (everolimus), Alecensa (alectinib), Alunbrig (brigatinib), Ayvakit (avapritinib), Balversa (erdafitinib), Besremi (ropeginterferon alfa-2b-njft), (NOTE: both Rx and Medical benefit drug), Bosulif (bosutinib), Braftovi (encorafenib), Brukinsa (zanubrutinib), Cabometyx (cabozantinib tablets), Calquence (acalabrutinib), Caprelsa (vandetanib), Cometriq (cabozantinib capsules), Copiktra (duvelisib), Cotellic (cobimetinib), Daurismo (glasdegib), Erivedge (vismodegib), Erleada (apalutamide), Exkivity (mobocertinib), Fotivda (tivozanib), Gavreto (pralsetinib), Gilotrif (afatinib), Hemady (dexamethasone), Ibrance (palbociclib), Iclusig (ponatinib), Idhifa (enasidenib), Imbruvica (ibrutinib), Inlyta (axitinib), Inqovi (decitabine/cedazuridine), Inrebic (fedratinib), Iressa (gefitinib), Jakafi (ruxolitinib), Jaypirca (pirtobrutinib), Kisqali and Kisqali Femara Co-Pack (ribociclib and ribociclib/letrozole), Koselugo (selumetinib), Krazati (adagrasib), Lenvima (lenvatinib), Lonsurf (trifluridine and tipiracil), Lorbrena (lorlatinib), Lumakras (sotorasib), Lynparza tablets (olaparib tablets), Lytgobi (futibatinib), Mekinist (trametinib), Mektovi (binimetinib), Nerlynx (neratinib), Nexavar (sorafenib), Sorafenib (generic Nexavar), Ninlaro (ixazomib), Nubeqa (darolutamide), Odomzo (sonidegib), Onureg (oral azacitidine), Orgovyx (relugolix), Orserdu (elacestrant), Pemazyre (pemigatinib), Piqray (alpelisib), Pomalyst (pomalidomide), Purixan (6-mercaptopurine), Qinlock (ripretinib), Retevmo (selpercatinib), Revlimid (lenalidomide), Rezlidhia (olutasidenib), Rezurock (belumosudil), Rozlytrek (entrecetinib), Rubraca (rucaparib), Rydapt (midostaurin), Scemblix (asciminib), Soltamox (tamoxifen citrate), Sprycel (dasatinib), Stivarga (regorafenib), Sutent (sunitinib), Tabrecta (capmatinib), Tafinlar (dabrafenib), Tagrisso (osimertinib), Talzenna (talazoparib), Tarceva (erlotinib), Targretin capsules (bexarotene capsules), Targretin gel (bexarotene gel), Tasigna (nilotinib), Tazverik (tazemetostat), Tepmetko (tepotinib), Tibsovo (ivosidenib), Truseltiq (infigratinib), Tukysa (tucatinib), Turalio (pexidartinib), Valchlor (mechlorethamine), Venclexta (venetoclax), Verzenio (abemaciclib), Vitrakvi (larotrectinib), Vizimpro (dacomitinib), Vonjo (pacritinib), Votrient (pazopanib), Welireg (belzutifan), Xalkori (crizotinib), Xermelo (telotristate ethyl), Xospata (gileritinib), Xpovio (selinexor), Xtandi (enzalutamide), Yonsa (abiraterone acetate, micronized), Zejula (niraparib), Zelboraf (vemurafenib), Zolinza (vorinostat), Zydelig (idelalisib), Zykadia (ceritinib), Zytiga (abiraterone acetate)) Open a PDF 5/18/2023
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 3/20/2023
Oncology (CRPA) Medical - (Abecma, Abraxane (paclitaxel protein bound particles), Adcetris (brentuximab vedotin), Aliqopa (copanlisib), Arzerra (ofatumumab), Asparlas (calaspargase pegol-mknl), Beleodaq (belinostat), Belrapzo (bendamustine HCL), Bendeka (bendamustine HCL)*, Besponsa (inotuzumab ozogamicin), Blenrep (belantamab mafodotin-blmf), Blincyto (blinatumomab), Breyanzi, Camcevi (leuprolide mesylate), Carvykti, Cyramza (ramucirumab), Danyelza (naxitamab-gqgk), Darzalex (daratumumab), Darzalex Faspro (daratumumab and hyaluronidase-fihj), Elahere (mirvetuximab soravtansine-gynx), Elitek (rasburicase), Elzonris (tragraxofusp-erzs), Empliciti (elotuzumab), Enhertu (fam-trastuzumab deruxtecan-nxki), Erwinaze (asparaginase), Folotyn (pralatrexate), Fyarro (sirolimus protein-bound particles), Gazyva (obinutuzumab), Istodax (romidepsin), Jelmyto (mitomycin gel), Kadcyla (ado-trastuzumab emtansine), Kimmtrak (tebentafusp), Kymriah, Kyprolis (carfilzomib), Lartruvo (olaratumab injection), leuprolide Acetate Depot, Lumoxiti (moxetumomab pasudotox-tdfk), Lunsumio (mosunetuzumab-axgb), Margenza (margetuximab-cmkb), Marqibo (vincristine sulfate liposome injection), Monjuvi (tafasitamab-cxix), Mylotarg (gemtuzumab ozogamicin), Oncaspar (pegaspargase), Onivyde (irinotecan liposome injection), Padcev (enfortumab vedotin-ejfv), Pedmark (sodium thiosulfate), Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf), Polivy (polatuzumab vedotin-piiq), Portrazza (necitumumab), Poteligeo (mogamulizumab-kpkc), Provenge (sipuleucel-T), Rybrevant (amivantamab-vmjw), Rylaze (asparaginase erwinia chrysanthemi [recombinant]-rywn), Sarclisa (isatuximab-irfc), Synribo (omacetaxine mepesuccinate), Tecvayli (teclistamab), Tecartus, Tivdak (tisotumab vedotin-tftv), Torisel (temsirolimus), Treanda (bendamustine HCL), Trodelvy (sacituzumab govitecan-hziy), Vivimusta (bendamustine HCL), Vyxeos, (Daunorubicin/Cytarabine), Yescarta, Yondelis (trabectedin), Zaltrap (ziv-aflibercept), Zepzelca (lurbinectedin), Zynlonta (loncastuximab tesirine-lpyl) Open a PDF 5/18/2023
Off Label Use Open a PDF 5/5/2022
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) - (Duexis, fenoprofen tablets, Flector, Licart, Lofena, diclofenac patches, indomethacin capsules, indomethacin suppositories, ketoprofen capsules, Naprelan, naproxen ER, naproxen suspension, Pennsaid, Qmiiz, Relafen DS, Seglentis, Sprix, ketorolac/tromethamine nasal spray, Tivorbex, Vimovo, Vivlodex, meloxicam capsules, Xelstrym, Zipsor, Zorvolex and diclofenac 35 mg capsules) Open a PDF 12/22/2022
Non-Formulary Medication Exception Review Policy Open a PDF 4/1/2023
Showing 1– 25 of 57 Results

 

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