Drug Policies

Showing 26– 50 of 81 Results
Title Last Updated
Geographic Atrophy Drug Policy (Izervay, Syfovre) (Health Professional Administered) - Medical Benefit Open a PDF 02/12/2026
Growth Hormone Policy Open a PDF 03/09/2026
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 01/01/2026
Hemophilia Gene Therapies Policy - (Hemgenix & Roctavian) - Medical Benefit Open a PDF 02/12/2026
Hepatitis-C Virus (HCV) Infection (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) (Self Administered) - Rx Benefit Open a PDF 03/13/2026
Hereditary Angioedema (HAE) for Andembry, Berinert, Cinryze, Dawnzera, Ekterly, Firazyr, Icatibant Haegarda, Kalbitor, Orladeyo, Ruconest, Sajazir, and Takhzyro (Self-Administered & Health Professional Administered) – Rx Benefit & Medical Benefit Open a PDF 03/05/2026
Immune Checkpoint Inhibitor (CPI) (Health Professional Administered) - (Bavencio, Imfinzi, Imjudo, Jemperli, Keytruda, Keytruda Qlex, Libtayo, Loqtorzi, Opdivo, Optivo, Opdualag, Qvantig, Tecentriq, Tecentriq Hybreza, Tevimbra, Unloxcyt, Yervoy, and Zynyz) - Medical Benefit Open a PDF 02/12/2026
Immune Thrombocytopenia (ITP) Drug Policy (Alvaiz, Doptelet and Doptelet Sprinkle, eltrombopag tablet and powder for suspension, Nplate, Promacta, Tavalisse, Wayrilz) (Self-Administered & Health Professional Administered) – Rx Benefit & Medical Benefit Open a PDF 01/30/2026
Inborn Errors of Metabolism Policy (Rx & Medical Benefit) – (Attruby, Amvuttra, Brineura, Carbaglu and generic carglumic acid, Cerdelga, Cerezyme, Cholbam, Crysvita, Ctexli, Dojolvi, Elaprase, Elelyso, Elfabrio, Fabrazyme, Galafold, Givlaari, Harliku, 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 11/19/2025
Infertility Medications Policy Open a PDF 10/08/2025
Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs - (Actemra (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 (Medical or Rx), Tofidence (Medical), Tyenne (Medical & Rx), Xeljanz and Xeljanz XR- tofacitinib and tofacitinib ER (Rx), Zeposia- ozanimod (Rx)) Open a PDF 02/12/2026
Interleukin Antagonists for Asthma and Other Conditions - (Health Professional Administered) Medical Benefit & (Self-Administered) Rx Benefit - (Adbry, Bullous Pemphigoid, Cinqair, Dupixent, Ebglyss, Fasenra, Nemluvio, & Nucala) Open a PDF 02/12/2026
Intravenous Immune Globulin (IVIG) & Sub-Cutaneous Immune Globulin (SCIG) Therapy (Alyglo, Asceniv, Bivigam, Cutaquig, Cuvitru, Flebogamma, Gammagard Liquid, Gammagard S/D powder, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, & Xembify) (Self-Administered) - Rx Benefit & (Health Professional Administered) - Medical Benefit Open a PDF 03/05/2026
Intravenous Iron Replacement Products Policy - Medical Benefit Open a PDF 11/19/2025
Kebilidi (eladocagene exuparvovec-tneq) (Health Professional Administered) - Medical Benefit Open a PDF 11/19/2025
Lantidra (donislecel-jujn) Drug Policy for Commercial, Essential Plan, Medicaid Managed Care & Medicare (Health Professional Administered) - Medical Benefit Open a PDF 02/12/2026
Low Clinical Impact for Rx Drugs Policy Open a PDF 02/19/2026
Lyfgenia (lovotibeglogene autotemcel) Drug Policy (Health Professional Administered) - Medical Benefit Open a PDF 01/01/2026
Medicare Part B Step Therapy Drug List Open a PDF 03/12/2026
Medicare Part D 2026 Prior Authorization Policy Open a PDF 03/01/2026
Medicare Part D 2026 Step Therapy Policy Open a PDF 03/01/2026
Medicare Part D Formulary Level Cumulative Opioid and Opioid / Buprenorphine POS Edits Open a PDF 03/11/2025
Monoclonal Antibodies for the Treatment of Hemophilia – (Health Professional Administered) Medical Benefit & (Self-Administered) Rx Benefit - (Alhemo, Hemlibra, Hympavzi, Qfitlia) Open a PDF 11/19/2025
Non-Formulary Medication Exception Review Policy Open a PDF 01/01/2026
Off-Label Use of FDA Approved Drugs Open a PDF 05/08/2025
Showing 26– 50 of 81 Results

 

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