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 51– 64 of 64 Results
Title Last Updated
Quantity Limit Open a PDF 03/20/2024
Rare Diseases CRPA Policy (Medical and Rx Benefits) - (Actimmune (Medical & Rx), Adzynma (Medical), Aldurazyme (Medical), Arcalyst (Rx), Bylvay (Rx), Camzyos (Rx), Cuprimine and generic penicillamine capsules (Rx), Cuvrior (Rx), Daybue (Rx), Empaveli (Rx), Enjaymo (Medical), Enspryng (Rx or Medical), Evkeeza (Medical), Fabhalta (Rx), Filspari (Rx), Firdapse (Rx), Gamifant (Medical), Hyftor 0.2% gel (Rx), Ilaris (Medical), Increlex (Rx), Isturisa (Rx), Joenja (Rx), Juxtapid (Rx), Keveyis (Rx), Korlym (Rx), Lanreotide Acetate Injection (Medical & Rx), Livmarli (Rx), Luxturna (Medical), Myalept (Rx), Mycapssa (Rx), Procysbi (Rx), Pyrukynd (Rx), Reblozyl (Medical), Recombinant (Rx), Recorlev (Rx), Rethymic (Medical), Revcovi - (Medical & Rx), rh-IGF-1 (Rx), Ruzurgi (Rx), Ryplazim (Medical & Rx), Rystiggo (Medical), Sandostatin LAR (Rx & Medical), Scenesse (Medical), Signifor LAR (Medical), Signifor SC (Rx), Skyclarys (Rx), Skysona (Medical), Sohonos (Rx), Soliris (Medical), Somavert (Rx), Sylvant (Medical), Syprine, generic trientine capsules (Rx), Tarpeyo (Rx), Tavneos (Rx), Tepezza (Medical), Thiola, Thiola EC and generic tiopronin (Rx), Tzield (Medical), Ultomiris (Medical), Uplizna (Medical), Veopoz (Medical), Vijoice (Rx), Voxzogo (Rx), Vyjuvek (Medical), Vyvgart (Medical), Vyvgart Hytrulo (Medical), Zilbrysq (Rx), Zokinvy (Rx), Ztalmy (Rx), Zynteglo (Rx)) Open a PDF 04/11/2024
Remicade® (infliximab), Infliximab, Renflexis® (infliximab-abda) Open a PDF 08/24/2023
Repository Corticotropin Injection (Medical & Rx Benefit) (Acthar HP and Purified Cortrophin gel) - for Infantile Spasms, Multiple Sclerosis Exacerbations Open a PDF 02/08/2024
Respiratory Syncytial Virus (RSV) Prophylaxis Open a PDF 11/30/2023
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 04/11/2024
Spinal Muscular Atrophy (SMA) – Evrysdi (risdiplam), Spinraza (nusinersen), Zolgensma (onasemnogene abeparovec-xioi) Open a PDF 01/11/2024
Stelara (ustekinumab) – for Crohn’s Disease, Plaque Psoriasis and Psoriatic Arthritis Open a PDF 12/06/2023
Step Therapy Drug Policy - Acyclovir 5% cream, Adapalene 0.1% (Lotion, Soln, Swab), Admelog, Adlarity, AirDuo Digihaler, AirDuo Respiclick, Alogliptin, Alogliptin/metformin, Alogliptin/pioglitazone, Alvesco, Amitiza, Amzeeq, Anzemet, Apidra, Armonair Digihaler, Aspart Insulin, Aczone 7.5%, Aubagio, Bafiertam, Belsomra, Blood Glucose Meters and Test Strips, Brexafemme, Budesonide/Formoterol, Caplyta, Clindagel 75 mL, Clindamycin 1% Gel 75 mL (Oceanside & Solaris), Dapagliflozin, Dapagliflozin/Metformin, Dapsone 7.5%, Dayvigo, Denavir 1% Cream, Dexilant, Dexlansoprazole DR, Differin 0.1% Lotion, Doryx, Doryx MPC, Doxycycline hyclate DR, Drizalma Sprinkle, Duaklir Pressair, Ecoza, Edarbi, Edarbyclor, Edluar, Emsam, Ertaczo, Estring, Eucrisa Ointment, Fanapt, Fiasp, Flovent Diskus and Flovent HFA, Fluticasone-Vilanterol, Fluticasone-salmeterol HFA, Forfivo XL 450mg, Fortamet, Gelnique, Glumetza, Ibsrela, Insulin Aspart, Invokamet, Invokamet XR, Invokana, Kazano, 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, Naftifine, Naftin Gel, Nesina, Norgesic Forte, Noritate, Novolin 70-30, Novolin N, Novolin R, Novolog, Novolog Mix 70/30, Omeprazole/Sodium Bicarbonate Packets, Onzetra Spray, Orphenadrine/Aspirin/Caffeine, Orphengesic Forte, Oseni, Osphena, Oxistat Lotion, Oxytrol, Pancreaze, Penciclovir 1% Cream, Pertzye, Pheburane, Ponvory, Praluent, Prograf Granules, Pulmicort Flexhaler, Qtern, Quviviq, Rezvoglar, Relistor Tablet, Restasis 0.05%, Restasis Multidose 0.05%, Rexulti, Rhopressa, Rocklatan, Savaysa, Sancuso, Savaysa, Savella, Secuado, Segluromet, Sernivo Lotion, Spiriva, Steglatro, Symproic, Tafluprost, Thalitone, Tosymra, Tudorza Pressair, Ultravate Lotion, Venlafaxine ER Tablets, Verdeso, 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, Zyclara 2.5% Cream Pump, Zyclara 3.75% Cream, Zyclara 3.75% Cream Pump, Zypitamag) Open a PDF 04/09/2024
Tezspire™ (tezepelumab-ekko subcutaneous injection) Open a PDF 02/08/2024
Viscosupplementation with Hyaluronic Acid Open a PDF 08/24/2023
Weight Management - Contrave, Orlistat, Qsymia, Saxenda, Wegovy, Xenical, Zepbound Open a PDF 04/11/2024
Xiaflex (collagenase clostridium histolyticum) Policy Open a PDF 08/24/2023
Xolair (omalizumab) Open a PDF 04/11/2024
Showing 51– 64 of 64 Results

 

GDPR Notification Content