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.

Make a Comment

We invite practitioners to review & comment on our policies.

Showing 26– 50 of 58 Results
Title Last Updated
Non-Formulary Medication Exception Review Policy Open a PDF 4/1/2023
Medicare Part D 2023 Step Therapy Policy Open a PDF 09/29/2023
Medicare Part D 2023 Prior Authorization Policy Open a PDF 09/29/2023
Medicare D Formulary-Level Cumulative Opioid and Opioid / Buprenorphine POS Edits Open a PDF 4/1/2023
Intravenous Immune Globulin (IVIG) & Sub-Cutaneous Immune Globulin (SCIG) Therapy Open a PDF 07/14/2023
Interleukin Antagonists for Asthma and Other Conditions: Nucala (mepolizumab), Cinqair (reslizumab), Fasenra (benralizumab), Dupixent (dupilumab), & Adbry (tralokinumab-ldrm) Open a PDF 07/13/2023
Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs - (Actemra - tocilizumab (Medical or Rx), Cibinqo - abrocitinib (Rx), Cosentyx - secukinumab (Rx), Entyvio – vedolizumab (Medical), 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), Xeljanz and Xeljanz XR- tofacitinib and tofacitinib ER (Rx), Zeposia- ozanimod (Rx)) Open a PDF 09/01/2023
Infertility Medications Open a PDF 09/11/2023
Inborn Errors of Metabolism & Rare Genetic Diseases - Amvuttra (vutrisiran), Brineura (cerliponase alfa), Carbaglu and generic carglumic acid, Cerdelga (eliglustat), Cerezyme (imiglucerase), Cholbam (cholic acid), Crysvita (burosumab-twza), Dojolvi (tripheptanoin oral liquid), Elaprase (idursulfase), Elelyso (taliglucerase alfa), Fabrazyme (agalisidase beta), Galafold (migalastat), Givlaari (givosiran) –, Javygtor and generic sapropterin, Kanuma (sebelipase alfa), Kuvan, Lamzede, Lumizyme (alglucosidase alfa), Mepsevii (vestronidase alfa-vjbk), Naglazyme (galsulfase), Nexviazyme (avalglucosidase alfa-ngpt), nitisinone capsule, Nityr (nitisinone) and Orfadin (nitisinone), Nulibry (fosdenopterin), Onpattro (patisiran), Oxlumo (lumasiran), Palynziq (pegvaliase-pqpz), Ravicti (glycerol phenylbutyrate), Strensiq (asfotase alfa), Sucraid (sacrosidase), Tegsedi (inotersen), Vimizim (elosulfase alfa)-Vimizim (elosulfase alfa), VPRIV (velaglucerase alfa), Vyndaqel (tafamidis meglumine), Vyndamax (tafamidis), Xenpozyme (olipudase alfa-rpcp), Xuriden (uridine triacetate), Zavesca / miglustat Open a PDF 8/16/2023
Immune Checkpoint Inhibitor (CPI) Clinical Review Prior Authorization (CRPA) (Bavencio, Imfinzi, Imjudo, Jemperli, Keytruda, Libtayo, Opdivo, Tecentriq, and Yervoy) Open a PDF 3/20/2023
Hereditary Angioedema (HAE) For Berinert, Cinryze, Firazyr, Icatibant Haegarda, Kalbitor, Orladeyo, Ruconest, Sajazir, and Takhzyro Open a PDF 3/15/2023
Hemlibra (emicizumab-kxwh) Open a PDF 12/15/2022
Hemgenix (etranacogene dezaparvovec-drlb) Open a PDF 2/14/2023
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 08/24/2023
Growth Hormone Policy Open a PDF 07/11/2023
Generic Advantage Program / MAC Penalty Open a PDF 07/10/2023
Enbrel (etanercept) – for Ankylosing Spondylitis, Juvenile Idiopathic Arthritis, Plaque Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis Open a PDF 08/24/2023
Duchenne Muscular Dystrophy (DMD): Amondys 45 (casimersen), Emflaza (deflazacort), Exondys 51 (eteplirsen), Viltepso (vilotarsen) and Vyondys 53 (golodirsen) Open a PDF 9/22/2022
Coronavirus (COVID-19) Impacted Drug Therapies (Hydroxychloroquine, Lagevrio (molnupiravir), Paxlovid (nirmatrelvir/ritonavir), Stromectol (ivermectin)) Open a PDF 4/1/2023
Compounded Drug Products Policy Open a PDF 08/11/2023
Clinical Review Prior Authorization Rx (CRPA) Open a PDF 09/20/2023
Clinical Review Prior Authorization (Medical Benefit) - (Briumvi (ublituximab-xiiy) (Medical), Cablivi (caplacizumab-yhdp) (Rx & Medical), Ceprotin (Protein C Concentrate, Human) (Medical), Eylea HD (aflibercept) (Medical), Fensolvi (leuprolide acetate), Hydroxyprogesterone Caproate Injection (Medical), Krystexxa - pegloticase (Medical), Lemtrada - alemtuzumab (Medical), Leqvio - inclisiran (Medical), Nplate - romiplostim (Medical), Ocrevus (ocrelizumab) (Medical), Rebyota - fecal microbiota,live-jslm (Medical), Saphnelo – anifrolumab-fnia (Medical), Spravato – esketamine nasal spray (Medical), Sunlenca (lenacapavir) (Rx & Medical), Supprelin LA (histrelin acetate) (Medical), Syfovre - pegcetacoplan injection (Medical), Triptodur (triptorelin), Trogarzo (ibalizumab-uiyk) (Medical), Trogarzo – ibalizumab-uiyk (Medical), Tysabri (natalizumab) (Medical), Vabysmo - faricimab-svoa (Medical), Zilretta – triamcinolone acetonide extended-release (Medical), Zoladex – goserelin implant (Medical), or any other medical agent) Open a PDF 9/12/2023
Cimzia (Certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis and Rheumatoid Arthritis Open a PDF 9/1/2023
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 04/01/2023
Chimeric Antigen Receptor T Cell (CAR-T) Therapy Open a PDF 11/15/2022
Showing 26– 50 of 58 Results

 

GDPR Notification Content