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
Zulresso (brexanolone injection) for Postpartum Depression Open a PDF 08/24/2023
Xolair (omalizumab) Open a PDF 07/13/2023
Xiaflex (collagenase clostridium histolyticum) Policy Open a PDF 08/24/2023
Weight Management - Contrave, Orlistat, Qsymia, Saxenda, Wegovy, Xenical, Zepbound Open a PDF 11/29/2023
Viscosupplementation with Hyaluronic Acid Open a PDF 08/24/2023
Tezspire™ (tezepelumab-ekko subcutaneous injection) Open a PDF 07/13/2023
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, Insulin Aspart, Kazano, Kombiglyze, Latanoprost/PF, Latuda, Livalo, Lonhala Magnair 25 mcg Refill & Starter, Luliconazole, Luzu, Lyuzeh, Metformin ER (generics of Fortamet and Glumetza), Metformin HCl 625 mg, Motegrity, Naftin Gel, Nesina, Norgesic Forte, Noritate, Novolog, 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, Savaysa, 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 11/10/2023
Stelara (ustekinumab) – for Crohn’s Disease, Plaque Psoriasis and Psoriatic Arthritis Open a PDF 08/24/2023
Spinal Muscular Atrophy (SMA) – Evrysdi (risdiplam), Spinraza (nusinersen), Zolgensma (onasemnogene abeparovec-xioi) Open a PDF 07/01/2023
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 8/16/2023
Respiratory Syncytial Virus (RSV) Prophylaxis Open a PDF 10/26/2023
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 08/24/2023
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), Tzield - teplizumab-mzwv (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 11/17/2023
Quantity Limit Open a PDF 09/11/2023
Pulmonary Hypertension (PH) - Adcirca (tadalafil (including Alyq)(Rx)), Adempas (riociguat (Rx)), epoprostenol (Medical)), Flolan, Letairis (ambrisentan (Rx)), Liqrev, Opsumit (macitentan (Rx)), Orenitram (treprostinil (Rx)), Remodulin (treprostinil (Medical)), Revatio (sildenafil (Rx)), Tadliq (Rx)), Tracleer (bosentan (Rx)), Tyvaso (treprostinil) inhalation (Rx), Tyvaso DPI (Rx)), Uptravi (selexipag) Rx)), Veletri (Medical), Ventavis (iloprost) inhalation (Medical)), & Combination Therapy (Ambrisentan and tadalafil) Open a PDF 6/8/2023
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 12/01/2023
Opioid Management Health and Safety Program- (Concurrent use of Opioid/Buprenorphine Products, Extended-release (long-acting) opioids, Morphine Milligram Equivalents (MME), Levorphanol, Opioid-naïve ADULT 7-day supply for first FOUR fills limit, Opioid-naïve PEDIATRIC 3-day supply for first FOUR fills limit, Opioid Cough & Cold medicines, Opioids drugs requiring Step Therapy, Oxaydo, Prolate Solution & Generic oxycodone-APAP 100-300mg/5ml, Prolate tablets, Primlev, Nalocet, & generic oxycodone-APAP 5mg/300mg and oxycodone-APAP 10mg/300mg & oxycodone-APAP 2.5mg/300mg, Roxybond, and Transmucosal Immediate-Release Fentanyl (TIRF) Medications) Open a PDF 09/19/2023
Oncology Clinical Review Prior Authorization Rx (Self Administration) - (Abiraterone 500 mg tablet, Afinitor (everolimus), Akeega (niraparib tosylate monohydrate and abiraterone acetate), 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), Disperz (everolimus), 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), Ojjaara (momelotinib), 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), Tukysa (tucatinib), Turalio (pexidartinib), Valchlor (mechlorethamine), Vanflyta (quizartinib), 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 11/20/2023
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 (Health Professional Administered) – Abraxane (paclitaxel protein-bound particles), Paclitaxel protein-bound particles (generic Abraxane), Paclitaxel protein-bound particles (American Regent 505(b)(2)), Adstiladrin (nadofaragene firadenovec-vncg), Adcetris (brentuximab vedotin), Aliqopa (copanlisib) Arzerra (ofatumumab), Asparlas (calaspargase pegol-mknl), Beleodaq (belinostat), Belrapzo (bendamustine HCL), Bendamustine HCL (Apotex 505(b)(2)), Bendamustine HCL (Baxter 505(b)(2)), Bendeka (bendamustine HCL, Bendeka (bendamustine HCL, Bendamustine HCL (generic Treanda), Vivimusta (bendamustine HCL), Besponsa (inotuzumab ozogamicin), Blincyto (blinatumomab), Camcevi (leuprolide mesylate), Columvi (glofitamab-gxbm) Cyramza (ramucirumab), Danyelza (naxitamab-gqgk), Darzalex (daratumumab), Darzalex Faspro (daratumumab and hyaluronidase-fihj), Elahere (mirvetuximab soravtansine-gynx), Elitek (rasburicase), Elrexfio (elranatamab-bcmm), Elzonris (tragraxofusp-erzs), Empliciti (elotuzumab), Enhertu (fam-trastuzumab deruxtecan-nxki), Epkinly (epcoritamab-bysp), Erwinaze (asparaginase), Folotyn (pralatrexate), Pralatrexate (generic Folotyn), Fyarro (sirolimus protein-bound particles), Gazyva (obinutuzumab), Infugem (gemcitabine), Istodax (romidepsin), Romidepsin (generic Istodax), Romidepsin (branded), Jelmyto (mitomycin gel), Kadcyla (ado-trastuzumab emtansine), Kimmtrak (tebentafusp), Kyprolis (carfilzomib), Lartruvo (olaratumab injection), Leuprolide Acetate Depot, Lumoxiti (moxetumomab pasudotox-tdfk), Lunsumio (mosunetuzumab-axgb), Margenza (margetuximab-cmkb), Monjuvi (tafasitamab-cxix), Mylotarg (gemtuzumab ozogamicin), Omisirge (omidubicel-onlv), Oncaspar (pegaspargase), Onivyde (irinotecan liposome injection), Padcev (enfortumab vedotin-ejfv), Pedmark (sodium thiosulfate), Pemfexy (pemetrexed), 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), Talvey (talquetamab-tgvs), Tecvayli (teclistamab), Tivdak (tisotumab vedotin-tftv), Torisel (temsirolimus), Temsirolimus (generic Torisel), Trodelvy (sacituzumab govitecan-hziy), Vyxeos (Daunorubicin/Cytarabine), Xgeva (denosumab), Yondelis (trabectedin), Zaltrap (ziv-aflibercept), Zepzelca (lurbinectedin), Zynlonta (loncastuximab tesirine-lpyl) Open a PDF 11/20/2023
Off Label Use Open a PDF 11/20/2023
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 8/24/2023
Showing 1– 25 of 64 Results

 

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