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 62 Results
Title Last Updated
Non-Formulary Medication Exception Review Policy Open a PDF 11/30/2023
Medicare Part D 2024 Step Therapy Open a PDF 02/29/2024
Medicare Part D 2024 Prior Authorization Policy Open a PDF 02/29/2024
Medicare D Formulary-Level Cumulative Opioid and Opioid / Buprenorphine POS Edits Open a PDF 11/30/2023
Intravenous Iron Replacement Products Policy Open a PDF 2/1/2024
Intravenous Immune Globulin (IVIG) & Sub-Cutaneous Immune Globulin (SCIG) Therapy – (Health Professional Administered) Rx & Medical Benefit (Asceniv, Bivigam, Cutaquig, Cuvitru, Flebogamma, Gammagard Liquid, Gammagard S/D powder, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, & Xembify) Open a PDF 03/11/2024
Interleukin Antagonists for Asthma and Other Conditions: Nucala (mepolizumab), Cinqair (reslizumab), Fasenra (benralizumab), Dupixent (dupilumab), & Adbry (tralokinumab-ldrm) Open a PDF 02/19/2024
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 12/06/2023
Infertility Medications Open a PDF 12/06/2023
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, 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 03/13/2024
Immune Checkpoint Inhibitor (CPI) (Health Professional Administered) Medical Benefit - (Bavencio, Imfinzi, Imjudo, Jemperli, Keytruda, Libtayo, Loqtorzi, Opdivo, Opdualag, Tecentriq, Yervoy, and Zynyz) Open a PDF 03/21/2024
Hereditary Angioedema (HAE) For Berinert, Cinryze, Firazyr, Icatibant Haegarda, Kalbitor, Orladeyo, Ruconest, Sajazir, and Takhzyro Open a PDF 02/08/2024
Hemophilia Gene Therapies Policy (Medical Benefits) – (Hemgenix & Roctavian) Open a PDF 03/13/2024
Hemlibra (emicizumab-kxwh) Open a PDF 12/06/2023
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 12/06/2023
Growth Hormone Policy Open a PDF 02/08/2024
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 12/06/2023
Duchenne Muscular Dystrophy (DMD) - Agamree, Amondys 45, Elevidys Emflaza and generic deflazacort, Exondys 51, Viltepso and Vyondys 53 Open a PDF 03/14/2024
Dual Special Needs Plan (D-SNP) 2024 Step Therapy Policy Open a PDF 02/29/2024
Dual Special Needs Plan (D-SNP) 2024 Prior Authorization Policy Open a PDF 02/29/2024
Diabetic Incretin Mimetic Agents Policy Open a PDF 01/01/2024
Coronavirus (COVID-19) Impacted Drug Therapies (Hydroxychloroquine, Lagevrio (molnupiravir), Paxlovid (nirmatrelvir/ritonavir), Stromectol (ivermectin)) Open a PDF 02/08/2024
Compounded Drug Products Policy Open a PDF 02/08/2024
Clinical Review Prior Authorization Rx (CRPA) Open a PDF 03/14/2024
Showing 26– 50 of 62 Results

 

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