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 72 Results
Title Last Updated
Ohtuvayre (ensifentrine) Policy for Commercial, Exchange, & SafetyNet - Rx Benefit; Medicare Advantage & DSNP - Medical Benefit Open a PDF 02/07/2025
Off-Label Use of FDA Approved Drugs Open a PDF 09/06/2024
Ocaliva (obeticholic acid) Drug Policy - Medical Benefit Open a PDF 01/01/2025
Non-Formulary Medication Exception Review Policy Open a PDF 10/15/2024
Monoclonal Antibodies for the Treatment of Hemophilia – (Health Professional Administered) Medical Benefit & (Self-Administered) Rx Benefit - (Hemlibra and Hympavzi) Open a PDF 01/08/2025
Medicare Part D Formulary Level Cumulative Opioid and Opioid / Buprenorphine POS Edits Open a PDF 11/30/2023
Medicare Part D 2025 Step Therapy Policy Open a PDF 01/01/2025
Medicare Part D 2025 Prior Authorization Policy Open a PDF 01/01/2025
Medicare Part B Step Therapy Drug List Open a PDF 02/01/2025
Lyfgenia (lovotibeglogene autotemcel) Drug Policy - Medical Benefit Open a PDF 12/19/2024
Low Clinical Impact for Rx Drugs Policy Open a PDF 01/31/2025
Lantidra (donislecel-jujn) - Medical Benefit (Commercial, Essential Plan, Medicaid Managed Care & Medicare) Open a PDF 12/15/2024
Intravenous Iron Replacement Products Policy - Medical Benefit Open a PDF 12/19/2024
Intravenous Immune Globulin (IVIG) & Sub-Cutaneous Immune Globulin (SCIG) Therapy – (Health Professional Administered) Rx & Medical Benefit (Alyglo, Asceniv, Bivigam, Cutaquig, Cuvitru, Flebogamma, Gammagard Liquid, Gammagard S/D powder, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, & Xembify) Open a PDF 01/13/2025
Interleukin Antagonists for Asthma and Other Conditions - (Health Professional Administered) Medical Benefit & (Self-Administered) Rx Benefit - (Adbry, Cinqair, Dupixent, Ebglyss, Fasenra, Nemluvio, & Nucala) Open a PDF 01/01/2025
Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs - Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs - (Actemra - tocilizumab (Medical or Rx), Bimzelx, Cibinqo - abrocitinib (Rx), Cosentyx - secukinumab (Rx), Ilumya – tildrakizumab-asmn (Medical), Kevzara – sarilumab (Rx), Kineret - anakinra (Rx), Olumiant – baricitinib (Rx), Orencia - abatacept (Medical or Rx), Otezla - apremilast (Rx), Rinvoq – upadacitinib (Rx), Siliq – brodalumab (Rx), Skyrizi – risankizumab-rzaa (Rx), Simponi - golimumab (Medical or Rx), Sotyktu (deucravacitinib) (Rx), Spevigo (spesolimab-sbzo) (Rx), Taltz – ixekizumab (Rx), Tremfya – guselkumab (Medical or Rx), Tyenne Actemra biosimilar), Xeljanz and Xeljanz XR- tofacitinib and tofacitinib ER (Rx), Zeposia- ozanimod (Rx)) Open a PDF 02/06/2025
Infertility Medications Policy Open a PDF 12/19/2024
Inborn Errors of Metabolism Policy (Rx & Medical Benefit) – (Attruby, 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 12/23/2024
Immune Checkpoint Inhibitor (CPI) (Medical Benefit) (Health Professional Administered) - (Bavencio, Imfinzi, Imjudo, Jemperli, Keytruda, Libtayo, Loqtorzi, Opdivo, Optivo Qvantig, Opdualag, Tecentriq, Tecentriq Hybreza, Tevimbra, Yervoy, and Zynyz) Open a PDF 02/03/2025
Hereditary Angioedema (HAE) For Berinert, Cinryze, Firazyr, Icatibant Haegarda, Kalbitor, Orladeyo, Ruconest, Sajazir, and Takhzyro Open a PDF 01/01/2025
Hemophilia Gene Therapies Policy - (Beqvez, Hemgenix & Roctavian) - Medical Benefit Open a PDF 12/15/2024
Headache Disorder – (Aimovig (erenumab-aooe) (Rx), Ajovy (fremanezumab-vfrm) (Rx & Medical), D.H.E 45, dihydroergotamine 1 mg/mL ampule (Rx), Elyxyb (celecoxib oral solution) Rx, Emgality 120 mg (galcanezumab-gnlm) (Rx), Emgality 300 mg (galcanezumab-gnlm) (Rx), Ergomar (ergotamine tartrate) Rx, Migranal, dihydroergotamine 4 mg/mL nasal spray, 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 01/02/2025
Growth Hormone Policy Open a PDF 01/08/2025
Geographic Atrophy Drug Policy (Health Professional Administered) - Medical Benefit (Izervay, Syfovre) Open a PDF 12/19/2024
Generic Advantage Program / MAC Penalty Open a PDF 07/10/2023
Showing 26– 50 of 72 Results

 

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