Revised: August 01, 2024
NYRx, the New York Medicaid Pharmacy Program
For more information on NYRx, the Medicaid Pharmacy Program: http://www.health.ny.gov/health_care/medicaid/program/pharmacy.htm
To contact the NYRx Clinical Call Center please call 1-877-309-9493
To download a copy of the Prior Authorization fax form go to https://newyork.fhsc.com/providers/PA_forms.asp
Disclaimer: Branded generics are included with the single generic name listing; they are not listed as separate agents.
1
OVERVIEW OF CONTENTS
Preferred Drug Program (PDP) (Pages 4–58)
The PDP promotes the use of less expensive, equally effective drugs when medically appropriate through a Preferred Drug List (PDL). All drugs currently covered
by NYRx, the Medicaid Pharmacy Program, remain available under the PDP and the determination of preferred and non-preferred drugs does not prohibit a
prescriber from obtaining any of the medications covered under Medicaid.
• Non-preferred drugs in these classes require prior authorization (PA), unless indicated otherwise.
• Preferred drugs that require prior authorization are indicated by footnote.
• Specific Clinical, Frequency/Quantity/Duration, Step Therapy criteria is listed in column at the right.
NOTE: Not all drugs covered by NYRx are subject to programs included in this document. For a complete list of drugs covered by NYRx see the
Medicaid Pharmacy List of Reimbursable Drugs
Clinical Drug Review Program (CDRP) (Page 59)
The CDRP is aimed at ensuring specific drugs are utilized in a medically appropriate manner. Under the CDRP, certain drugs require prior authorization because
there may be specific safety issues, public health concerns, the potential for fraud and abuse, or the potential for significant overuse and misuse.
Drug Utilization Review (DUR) Program (Pages 60–72)
The DUR helps to ensure that prescriptions for outpatient drugs are appropriate, medically necessary, and not likely to result in adverse medical consequences.
This program uses professional medical protocols and computer technology and claims processing to assist in the management of data regarding the prescribing
and dispensing of prescriptions. Frequency/Quantity/Duration (F/Q/D) Program and Step Therapy parameters are implemented to ensure clinically appropriate
and cost-effective use of these drugs and drug classes.
Medication Assisted Treatment (MAT) Formulary (Page 73)
Prior authorization will not be required for medications used for the treatment of substance use disorder prescribed according to generally accepted national
professional guidelines for the treatment of a substance use disorder.
Brand Less Than Generic (BLTG) Program (Pages 74–75)
The Brand Less Than Generic Program is a cost containment initiative which promotes the use of certain multi-source brand name drugs when the cost of the
brand name drug is less expensive than the generic equivalent. This program is in conformance with State Education Law, which intends that patients receive the
lower cost alternative.
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
2
Mandatory Generic Drug Program (Page 76)
State law excludes Medicaid coverage of brand name drugs that have a Federal Food and Drug Administration (FDA) approved A-rated generic equivalent unless
a prior authorization is obtained. Drugs subject to the Preferred Drug Program (PDP), Clinical Drug Review Program (CDRP), and/or the Brand Less Than Generic
(BLTG) Program are not subject to the Mandatory Generic Program.
Dose Optimization Program (Pages 77–81)
Dose optimization can reduce prescription costs by reducing the number of pills a patient needs to take each day. The Department has identified drugs to be
included in this program, the majority of which have FDA approval for once-a-day dosing, have multiple strengths available in correlating increments at similar
costs and are currently being utilized above the recommended dosing frequency.
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
3
PREFERRED DRUG LIST – TABLE OF CONTENTS
I. ANALGESICS ..................................................................................................................................................................................................... 4
II. ANTI-INFECTIVES.............................................................................................................................................................................................. 7
III. CARDIOVASCULAR .......................................................................................................................................................................................... 9
IV. CENTRAL NERVOUS SYSTEM ......................................................................................................................................................................... 14
V. DERMATOLOGIC AGENTS ............................................................................................................................................................................... 25
VI. ENDOCRINE AND METABOLIC AGENTS .......................................................................................................................................................... 31
VII. GASTROINTESTINAL ..................................................................................................................................................................................... 37
VIII. HEMATOLOGICAL AGENTS .......................................................................................................................................................................... 41
IX. IMMUNOLOGIC AGENTS ............................................................................................................................................................................... 44
X. MISCELLANEOUS AGENTS .............................................................................................................................................................................. 46
XI. MUSCULOSKELETAL AGENTS ......................................................................................................................................................................... 47
XII. OPHTHALMICS ............................................................................................................................................................................................. 48
XIII. OTICS .......................................................................................................................................................................................................... 51
XIV. RENAL AND GENITOURINARY ..................................................................................................................................................................... 52
XV. RESPIRATORY .............................................................................................................................................................................................. 55
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 4
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
I. Analgesics
Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)
Celebrex®
celecoxib
diclofenac 1% topical gel
diclofenac sodium oral
ibuprofen Rx tablet, suspension
ibuprofen OTC suspension
indomethacin capsule
ketorolac
meloxicam tablet
nabumetone
naproxen tablet
piroxicam
sulindac
Arthrotec®
Daypro®
diclofenac epolamine patch (gen
Flector®)
diclofenac capsule
diclofenac/misoprostol
diclofenac potassium
diclofenac potassium (gen Cambia®)
diclofenac sodium ER
diclofenac topical soln
diflunisal
Duexis®
Elyxyb™
F/Q/D
etodolac
etodolac ER
Feldene®
fenoprofen
Flector® patch
flurbiprofen
ibuprofen/famotidine (gen Duexis®)
indomethacin ER
indomethacin suspension
ketoprofen
ketoprofen ER
ketorolac nasal spray (gen Sprix®)
Kiprofen™
Licart™
meclofenamate
mefenamic acid
meloxicam capsule (gen Vivlodex®)
Nalfon®
Naprelan®
FREQUENCY/QUANTITY/DURATION (F/Q/D)
• Elyxyb™ (celecoxib) – 4.8 mL bottle (120 mg) maximum quantity: 9 / 30
days
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 5
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
I. Analgesics
naproxen susp
naproxen CR
naproxen EC
naproxen-esomeprazole
naproxen sodium
oxaprozin
Relafen® DS
tolmetin
Vimovo®
Opioids – Long-Acting
CC
buprenorphine patch
fentanyl patch (12 mcg, 25 mcg, 50 mcg,
75 mcg, 100 mcg)
morphine sulfate ER tablet)
Belbuca®
Butrans®
ConZip®
ST
fentanyl patch (37.5 mcg, 62.5 mcg,
87.5 mcg)
hydrocodone ER
hydrocodone ER (gen Hysingla ER)
hydromorphone ER
Hysingla® ER
morphine ER capsule (gen Avinza)
morphine ER capsule (gen Kadian)
MS Contin®
Nucynta® ER
ST
oxycodone ER
Oxycontin®
oxymorphone ER
tramadol ER
ST
Xtampza® ER
CLINICAL CRITERIA (CC) *
• Limited to a total of 4 opioid prescriptions every 30 days; Exemption for
diagnosis of cancer, hospice or palliative care, or sickle cell disease
• PA required for initiation of opioid therapy for patients on established
opioid dependence therapy
• PA required for use if ≥ 90 MME (MME = morphine milligram equivalents)
of opioid per day for management of non-acute pain (pain lasting > 7 days)
• PA required for initiation of long-acting opioid therapy in opioid-naïve
patients.
• PA required for any additional long-acting opioid prescription for patients
currently on long-acting opioid therapy.
• PA required for initiation of opioid therapy in patients currently on
benzodiazepine therapy
• PA required for any codeine- or tramadol-containing products in pts < 12
years
STEP THERAPY (ST)
• Nucynta® ER (tapentadol ER): Trial with tapentadol IR before tapentadol
ER for patients who are naïve to a long-acting opioid
• Tramadol ER (tramadol naïve patients): Attempt treatment with IR
formulations before the following ER formulations: ConZip®, tramadol ER
*Exemption from requirements for diagnosis of cancer, sickle cell disease, or
hospice or palliative care.
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 6
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
I. Analgesics
Opioids – Short-Acting
CC
butalbital/APAP/caffeine/codeine
codeine
codeine/APAP
hydrocodone/APAP
hydrocodone/ibuprofen
hydromorphone
tablets
morphine IR
oxycodone IR tablets, solution
oxycodone/APAP
tramadol tablet
butalbital compound/codeine
butorphanol nasal spray
dihydrocodeine/APAP/caffeine
Dilaudid®
hydromorphone
solution
levorphanol
meperidine
Nalocet®
Nucynta®
ST
oxycodone
IR capsules, concentrate
oxycodone/APAP (Prolate) solution,
tablets)
oxymorphone
pentazocine/naloxone
Percocet®
Roxicodone®
Seglentis®
tramadol solution
tramadol 25mg tablet
tramadol/APAP
CLINICAL CRITERIA (CC) *
• Limited to a total of 4 opioid prescriptions every 30 days.
• Initial prescription for opioid-naïve patients limited to a 7-day supply.
• PA required for initiation of opioid therapy for patients on established
opioid dependence therapy.
• PA required for use if ≥ 90 MME of opioid per day for management of non-
acute pain (> 7 days)
− Exception for diagnosis of cancer or sickle cell disease, or hospice or
palliative care programs
• PA is required for opioid-naïve patients for prescription requests ≥ 50
MME per day.
• PA required for continuation of opioid therapy beyond an initial 7-day
supply in patients established on gabapentin or pregabalin
• PA required for initiation of opioid therapy in patients currently on
benzodiazepine therapy
• PA required for any codeine- or tramadol-containing products in pts < 12
years
PA required for continuation of opioid therapy for >7days for patients on
established CNS stimulant therapy
STEP THERAPY (ST)
• Nucynta® (tapentadol IR) – Trial with tramadol and 1 preferred opioid
before tapentadol immediate-release (IR)
• For Non-opioid Pain management alternatives please visit:
https://health.ny.gov/health_care/medicaid/program/opioid_managemen
t/docs/non_opioid_alternatives_to_pain_management.pdf
*Exemptions from requirements for diagnosis of cancer, sickle cell disease, or
hospice or palliative care
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 7
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
II. Anti-Infectives
Antibiotics – Inhaled
CC, F/Q/D
Bethkis®
BLTG
Cayston®
Kitabis® Pak
BLTG
TOBI Podhaler™
tobramycin (gen TOBI®) solution
TOBI® solution
tobramycin (gen Bethkis®, Kitabis®)
solution
CLINICAL CRITERIA (CC)
• Confirm diagnosis of FDA-approved or compendia-supported indication
FREQUENCY/QUANTITY/DURATION (F/Q/D)
• Aztreonam (Cayston)
− 3 ampules (3 mL) per day
− 84 ampules (84 mL) per 56-day regimen (28 days on, 28 days off)
• Tobramycin inhalation solution (Bethkis, TOBI, Kitabis Pak)
− 2 ampules (8 mL Bethkis, 10 mL TOBI, Kitabis Pak) per day
− 56 ampules (224 mL Bethkis, 280 mL TOBI, Kitabis Pak) per 56-day
regimen (28 days on-28 days off)
• Tobramycin capsules with inhalation powder (TOBI Podhaler)
− 8 capsules per day 224 capsules per 56-day regimen (28 days on-28
days off)
Anti-Fungals – Oral for Onychomycosis
griseofulvin suspension, ultramicronized
terbinafine tablet
griseofulvin tablet
itraconazole
itraconazole solution (gen Sporanox)
Sporanox®
Anti-Virals – Oral
acyclovir
valacyclovir
famciclovir
Valtrex®
Cephalosporins – Third Generation
cefdinir
cefixime
cefpodoxime
Fluoroquinolones – Oral
ciprofloxacin suspension, tablet
levofloxacin tablet
Baxdela®
Cipro® suspension, tablet
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 8
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
II. Anti-Infectives
levofloxacin solution
moxifloxacin
ofloxacin tablet
Hepatitis B Agents
adefovir dipivoxil
Baraclude®
solution
entecavir
lamivudine HBV
Baraclude®
tablet
Hepsera®
Vemlidy®
Hepatitis C Agents – Direct Acting Antivirals
Mavyret™
ribavirin
sofosbuvir/velpatasvir
(gen Epclusa®)
Vosevi®
Epclusa®
Harvoni®
ledipasvir/sofosbuvir
(gen Harvoni®)
Sovaldi®
Zepatier®
Tetracyclines
demeclocycline
doxycycline hyclate
minocycline capsule
tetracycline capsule
Doryx®
ST
Doryx MPC®
ST
doxycycline hyclate DR
ST
doxycycline monohydrate
minocycline tablet
minocycline ER tablet
Minolira ER™
Nuzyra™
Solodyn®
tetracycline tablet
Vibramycin®
STEP THERAPY (ST)
• Trial of doxycycline IR before progressing to doxycycline DR
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 9
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
III. Cardiovascular
Angiotensin Converting Enzyme Inhibitors (ACEIs)
benazepril
enalapril
lisinopril
ramipril
Accupril®
Altace®
captopril
enalapril (gen Epaned®)
Epaned®
fosinopril
Lotensin®
moexipril
perindopril
Qbrelis™
quinapril
trandolapril
Vasotec®
Zestril®
ACE Inhibitor Combinations
benazepril/amlodipine
benazepril/HCTZ
captopril/HCTZ
enalapril/HCTZ
lisinopril/HCTZ
Lotrel®
trandolapril/verapamil ER
Accuretic®
fosinopril/HCTZ
Lotensin HCT®
quinapril/HCTZ
Vaseretic®
Zestoretic®
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 10
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
III. Cardiovascular
Angiotensin Receptor Blockers (ARBs)
irbesartan
losartan
olmesartan
telmisartan
valsartan tablet
Atacand®
Avapro®
Benicar®
DO
candesartan
Cozaar®
Diovan®
DO
Edarbi®
eprosartan
Micardis®
DO
valsartan solution
DOSE OPTIMIZATION (DO)
• See Dose Optimization Chart for affected drugs and strengths
Antianginals and Anti-Ischemics
ranolazine
Aspruzyo Sprinkle™
Ranexa®
ARBs Combinations
Entresto®
Exforge HCT®
irbesartan/HCTZ
losartan/HCTZ
olmesartan/amlodipine
olmesartan/HCTZ
telmisartan/HCTZ
valsartan/amlodipine
valsartan/amlodipine/HCTZ
valsartan/HCTZ
Atacand HCT®
Avalide®
Azor®
Benicar HCT®
DO
candesartan/HCTZ
Diovan HCT®
DO
Edarbyclor®
DO
Exforge®
DO
Hyzaar®
Micardis HCT®
DO
olmesartan/amlodipine/HCTZ
telmisartan/amlodipine
Tribenzor®
DOSE OPTIMIZATION (DO)
• See Dose Optimization Chart for affected drugs and strengths
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 11
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
III. Cardiovascular
Beta Blockers
atenolol
carvedilol
labetalol
metoprolol succ. XL
metoprolol tartrate
propranolol tablet
propranolol ER
acebutolol
betaxolol
bisoprolol
Bystolic®
DO
carvedilol ER
Coreg®
Coreg CR®
DO
Corgard®
Inderal LA®
Inderal XL®
InnoPran XL®
Kapspargo™ Sprinkle
Lopressor®
nadolol
DO
nebivolol (gen Bystolic®)
pindolol
propranolol solution
Tenormin®
timolol
Toprol XL®
DO
DOSE OPTIMIZATION (DO)
• See Dose Optimization Chart for affected drugs and strengths
Beta Blockers / Diuretics
atenolol/chlorthalidone
bisoprolol/HCTZ
propranolol/HCTZ
metoprolol tartrate/ HCTZ
Tenoretic®
Ziac®
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 12
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
III. Cardiovascular
Calcium Channel Blockers (Dihydropyridine)
amlodipine
felodipine ER
isradipine
nicardipine HCl
nifedipine
nifedipine ER/SA
Katerzia™
levamlodipine
nisoldipine
Norliqva®
Norvasc®
Procardia XL®
Sular®
Cholesterol Absorption Inhibitors
cholestyramine
cholestyramine light
Colestid
®
tablet
colestipol tablet
ezetimibe
colesevelam
Colestid granules, packet
colestipol granules, packet
Questran®
Questran Light®
Welchol®
Zetia®
HMG-CoA Reductase Inhibitors (Statins)
atorvastatin
lovastatin
pravastatin
rosuvastatin
simvastatin
Altoprev®
Atorvaliq®
atorvastatin/amlodipine
Caduet®
Ezallor™ Sprinkle
ezetimibe/simvastatin
fluvastatin
fluvastatin ER
Lescol XL®
Lipitor®
Livalo®
pitavastatin (gen Livalo®)
Vytorin®
Zocor®
Zypitamag™
DOSE OPTIMIZATION (DO)
• See Dose Optimization Chart for affected drugs and strengths
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 13
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
III. Cardiovascular
Phosphodiesterase Type-5 (PDE-5) Inhibitors for PAH
CC
sildenafil
tadalafil
Adcirca®
Liqrev®
Opsynvi®
Revatio®
Tadliq®
CLINICAL CRITERIA
• All prescriptions for Adcirca®, tadalafil, Revatio®,
and sildenafil must have
PA
• Prescribers or their authorized agents are required to respond to a series
of questions that identify prescriber, patient, and reason for prescribing
drug
• Please be prepared to fax clinical documentation upon request
• Prescriptions can be written for a 30-day supply with up to 11 refills
Pulmonary Arterial Hypertension (PAH) Agents, Other – Oral
ambrisentan (gen Letairis®)
bosentan tablets (gen Tracleer®)
Adempas®
Letairis®
Opsumit®
Orenitram®
ER
tablet, dosepack
Tracleer®
tablet for suspension, tablet
Uptravi®
Triglyceride Lowering Agents
fenofibrate tablet (gen Tricor®)
fenofibrate capsule (gen Lofibra®)
fenofibric acid capsule (gen Trilipix®)
gemfibrozil
omega-3 ethyl ester (gen Lovaza®)
F/Q/D,
Vascepa®
F/Q/D, BLTG
fenofibrate caps (gen Lipofen®)
fenofibrate micronized capsule
fenofibrate tablet (gen Fenoglide®)
fenofibric acid tablet (gen Fibricor®)
Fenoglide®
Fibricor®
icosapent (gen Vascepa®)
F/Q/D
Lipofen®
Lopid®
Lovaza®
F/Q/D
Tricor®
Trilipix®
FREQUENCY/QUANTITY/DURATION (F/Q/D)
• Lovaza® (omega-3-acid ethyl-esters) and Vascepa® (icosapent ethyl) –
Required dosage equal to 4 grams per day
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 14
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
IV. Central Nervous System
Alzheimer’s Agents
donepezil 5 mg, 10 mg
galantamine
galantamine ER
memantine
Namenda®
rivastigmine
Adlarity®
Aricept®
donepezil 23 mg
Exelon®
memantine ER
Namenda XR®
Namzaric®
Anticonvulsants – Carbamazepine Derivatives
carbamazepine chewable, tablet
carbamazepine ER capsule
Equetro®
oxcarbazepine tablet
Tegretol® suspension
BLTG
Tegretol XR®
BLTG
Trileptal® suspension
BLTG
Aptiom®
CC, DO
carbamazepine suspension
CC
carbamazepine XR tablet
Carbatrol®
CC
oxcarbazepine suspension
Oxtellar XR®
CC, DO
Tegretol® tablet
CC
Trileptal® tablet
CC
CLINICAL CRITERIA (CC)
• Clinical editing will allow patients currently stabilized on a non-preferred
agent to continue to receive that agent without PA
DOSE OPTIMIZATION (DO)
• See Dose Optimization Chart for affected drugs and strengths
Anticonvulsants – Other
clobazam tablet
ST, CC
gabapentin capsule, solution, tablet
F/Q/D, CC
lacosamide tablet, solution
lamotrigine tablet, chew
levetiracetam
levetiracetam ER
Lyrica® capsule
DO, F/Q/D, CC
pregabalin capsule
DO, F/Q/D, CC
tiagabine
topiramate
CC
Banzel®
Briviact®
clobazam suspension
ST
Diacomit®
CC
Elepsia® XR
Epidiolex®
CC
Eprontia™
CC
felbamate
Felbatol®
Fintepla®
Fycompa®
DO
DOSE OPTIMIZATION (DO)
• See Dose Optimization Chart for affected drugs and strengths
CLINICAL CRITERIA (CC)
• Clinical editing will allow patients currently stabilized on a non-preferred
agent to continue to receive that agent without PA
• Cannabidiol extract (Epidiolex®) – Confirm diagnosis of FDA-approved or
compendia-supported indication, or; Institutional Review Board (IRB)
approval with signed consent form
• Lyrica®/Lyrica® CR (pregabalin) – PA required for the initiation of
pregabalin at > 150 mg per day in patients currently on an opioid at > 50
MME per day
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 15
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
IV. Central Nervous System
zonisamide
Keppra®
Keppra XR®
Lamictal® tablet, chew, dosepak
Lamictal® ODT tablet, dosepak
Lamictal® XR
DO
tablet, dosepak
lamotrigine dosepak
lamotrigine ER
lamotrigine ODT dosepak
Lyrica® solution
DO, F/Q/D
Lyrica® CR
F/Q/D, CC
Motpoly XR
Neurontin®
F/Q/D, CC
Onfi®
ST, CC
pregabalin solution
DO, F/Q/D, CC
pregabalin ER (gen Lyrica® CR)
F/Q/D, CC
Qudexy® XR
CC
rufinamide (gen Banzel®)
Sabril®
Spritam®
Sympazan® film
ST, CC
Topamax®
CC
topiramate ER
CC, DO
(gen Qudexy® XR)
topiramate ER
CC
(gen Trokendi XR®)
Trokendi XR®
CC, DO
vigabatrin
Vimpat®
Xcopri®
Zonisade™
Ztalmy®
• Neurontin® (gabapentin) – PA required for initiation of gabapentin at >
900 mg per day in patients currently on an opioid at > 50 MME per day
• Stiripentol (Diacomit®) – Require diagnosis of FDA-approved or
compendia-supported indication, or; Institutional Review Board (IRB)
approval with signed consent form
• Topiramate IR/ER (Eprontia™, Qudexy® XR, Topamax®, Trokendi XR™) –
Require confirmation of FDA-approved, compendia-supported, or
Medicaid covered diagnosis
• Onfi®/Sympazan® (clobazam):
− Require confirmation of FDA-approved or compendia-supported use
− PA required for initiation of clobazam therapy in patients currently
on opioid or oral buprenorphine therapy
− PA required for any clobazam prescription in patients currently on
benzodiazepine therapy
FREQUENCY/QUANTITY/DURATION (F/Q/D)
• Eprontia™ (topiramate) – Maximum quantity: 473 mL per month
• Lyrica®/Lyrica® CR (pregabalin) – Maximum daily dose of IR: 600 mg per
day, and ER: 660 mg per day
• Neurontin® (gabapentin) – Maximum daily dose of 3,600 mg per day
STEP THERAPY (ST)
• Onfi®/Sympazan® (clobazam) – Requires a trial with an SSRI or SNRI for
treatment of anxiety
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 16
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
IV. Central Nervous System
Antimigraine Agents, Other
ST, F/Q/D
Aimovig®
Ajovy®
Emgality®
Nurtec™ ODT
Ubrelvy™
Emgality® 100mg syringe
Qulipta™
Reyvow™
Zavzpret™
STEP THERAPY (ST)
Acute treatment of migraine
• Trial of a product from the Antimigraine Agents-Triptan class
Prevention of migraine
Trial of 2 FDA approved or compendia supported migraine
prevention products from other drug classes
Agent
F/Q/D
Aimovig
1 syringe/30 days
Emgality 120 mg
2 syringes/30 days
Emgality 100 mg
3 syringes/30 days
Ajovy
3 syringes/90 days
Reyvow
8 units/30 days
Ubrelvy
16 units/30 days
Nurtec™ ODT
24 units/40 days
Qulipta
30 units/30 days
Zavzpret®
8 units/30 days
Antimigraine Agents − Triptans
rizatriptan
F/Q/D
sumatriptan
F/Q/D
almotriptan
F/Q/D
eletriptan
F/Q/D
Frova®
F/Q/D
frovatriptan
F/Q/D
Imitrex®
F/Q/D
Maxalt®
F/Q/D
Maxalt® MLT
F/Q/D
naratriptan
F/Q/D
Relpax®
F/Q/D
sumatriptan-naproxen
F/Q/D
Tosymra™
F/Q/D
FREQUENCY/QUANTITY/DURATION (F/Q/D)
Agent
F/Q/D
almotriptan
eletriptan (Relpax®)
frovatriptan (Frova®)
naratriptan
rizatriptan (Maxalt®)
rizatriptan (Maxalt® MLT)
sumatriptan nasal spray (Imitrex®)
sumatriptan (Imitrex®)
18 units/30 days
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 17
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
IV. Central Nervous System
Zembrace™ SymTouch™
zolmitriptan
F/Q/D
Zomig®
F/Q/D
sumatriptan-naproxen
Tosymra™ nasal spray
zolmitriptan (Zomig®)
Zomig® nasal spray
Antipsychotics – Injectable
Abilify Asimtufii®
Abilify Maintena®
Aristada®
Aristada Initio®
fluphenazine decanoate
Haldol® decanoate
haloperidol decanoate
Invega Hafyera™
Invega Sustenna®
Invega Trinza®
Perseris™
Risperdal Consta®
BLTG
Uzedy™
Zyprexa Relprevv®
risperidone injection (gen Risperdal
Consta®)
Rykindo®
Antipsychotics – Second Generation
CC, ST
aripiprazole tablet
DO
asenapine (gen Saphris®)
clozapine
lurasidone (gen Latuda®)
olanzapine tablet
DO
paliperidone ER
DO
quetiapine
F/Q/D
quetiapine ER
F/Q/D, DO
risperidone
Abilify® tablet
DO
Abilify MyCite®
aripiprazole solution
aripiprazole ODT
Caplyta™
clozapine ODT
Clozaril®
Fanapt®
Geodon®
DOSE OPTIMIZATION (DO)
• See Dose Optimization Chart for affected drugs and strengths
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 18
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
IV. Central Nervous System
ziprasidone capsule
Invega®
DO
Latuda®
DO
Lybalvi™
Nuplazid®
olanzapine ODT
DO
Rexulti®
DO
Risperdal®
Saphris®
Secuado®
Seroquel®
F/Q/D
Seroquel XR®
DO, F/Q/D
Versacloz®
Vraylar®
DO
Zyprexa®
DO
Zyprexa® Zydis
CLINICAL CRITERIA (CC)
• Confirm diagnosis of FDA-approved or compendia-supported indication
• Clinical editing will allow patients currently stabilized on a non-preferred
agent to continue to receive that agent without PA
• Prior authorization is required when an oral SGA is utilized above the
highest MDD according to FDA labeling.
• Prior authorization is required for patients less than 21 years of age when
there is concurrent use of 2 or more different oral antipsychotics for
greater than 90 days.
• Prior authorization is required for patients 21 years of age or older when 3
or more different oral second-generation antipsychotics are used for more
than 180 days.
• PA is required for initial prescription for beneficiaries younger than the
drug-specific minimum age as indicated below:
aripiprazole (Abilify®)
6 years
aripiprazole (Abilify MyCite®)
18 years
asenapine (Saphris®)
10 years
asenapine (Secuado®)
18 years
brexpiprazole (Rexulti®)
13 years
cariprazine (Vraylar®)
18 years
clozapine (Clozaril®, Versacloz®)
12 years
iloperidone (Fanapt®)
18 years
lumateperone (Caplyta™)
18 years
lurasidone HCl (Latuda®)
10 years
olanzapine (Zyprexa®)
10 years
paliperidone ER (Invega®)
12 years
pimavanserin (Nuplazid®)
18 years
quetiapine fum. (Seroquel®, Seroquel XR®)
10 years
risperidone (Risperdal®)
5 years
ziprasidone HCl (Geodon®)
10 years
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 19
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
IV. Central Nervous System
• Require confirmation of diagnosis that supports the concurrent use of a
Second Generation Antipsychotic and a CNS Stimulant for patients < 18
years of age
STEP THERAPY (ST)
• For all Second Generation Antipsychotics used in the treatment of Major
Depressive Disorder in the absence of other psychiatric comorbidities, trial
with at least two different antidepressant agents is required
FREQUENCY/QUANTITY/DURATION (F/Q/D)
• quetiapine/quetiapine ER (Seroquel®/Seroquel XR®): Minimum 50
mg/day
• quetiapine (Seroquel®): Maximum 3 units per day, 90 units per 30 days
• quetiapine ER (Seroquel XR®): Maximum150 mg, 1 unit/day, 30 units/30
days
• quetiapine ER (Seroquel XR®): Maximum 50 mg, 2 units/day, 60 units/30
days
Central Nervous System (CNS) Stimulants
CC, F/Q/D
amphetamine salt combo IR (gen
Adderall®)
amphetamine salt combo ER (gen
Adderall XR®)
DO
Daytrana®
BLTG
dexmethylphenidate (gen Focalin®)
dexmethylphenidate ER
DO
(gen Focalin
XR®)
dextroamphetamine tablet
lisdexamfetamine chewable tablet (gen
Vyvanse® chew tablet)
methylphenidate solution (gen
Methylin®)
methylphenidate tablet (gen Ritalin®)
methylphenidate CD
DO
Adderall XR®
DO
Adzenys XR-ODT®
amphetamine (gen Adzenys ER®)
amphetamine (gen Evekeo®)
Aptensio XR®
armodafinil (gen Nuvigil®)
Azstarys™
Concerta®
DO
Cotempla® XR-ODT™
Dexedrine®
dextroamphetamine / amphetamine
(gen Mydayis™)
dextroamphetamine ER (gen
Dexedrine®)
dextroamphetamine solution (gen
ProCentra®)
CLINICAL CRITERIA (CC)
• Confirm diagnosis of FDA-approved, compendia-supported and Medicaid
covered indication
• Prior authorization is required for initial prescriptions for stimulant
therapy for beneficiaries less than 3 years of age
• Confirm diagnoses that support concurrent use of CNS Stimulant and
Second Generation Antipsychotic agent for beneficiaries less than 18 years
of age
• Patient-specific considerations for drug selection include treatment of
narcolepsy, excessive daytime sleepiness, sleepiness associated with shift
work sleep disorder, or sleepiness associated with obstructive sleep
apnea.
• PA required for initiation of CNS Stimulant for patients currently on an
opioid.
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 20
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
IV. Central Nervous System
methylphenidate ER (gen Aptensio®
XR)
methylphenidate ER (gen Concerta®)
methylphenidate ER (gen Metadate
CD)
Ritalin LA®
DO, BLTG,
Vyvanse® capsule
DO, BLTG
dextroamphetamine tablet (gen
Zenzedi®)
Dyanavel XR®
Evekeo®
Evekeo® ODT
Focalin®
Focalin XR®
DO
Jornay PM™
lisdexamfetamine capsule (gen
Vyvanse®)
methamphetamine (gen Desoxyn®)
Methylin®
methylphenidate (gen Daytrana®)
methylphenidate chewable tablet (gen
Methylin®)
methylphenidate ER 45 mg, 63 mg,
72 mg tablet
methylphenidate ER (gen Ritalin LA®)
modafinil (gen Provigil®)
DO
Mydayis™
Nuvigil®
ProCentra®
Provigil®
DO
QuilliChew ER™
DO
Quillivant XR®
Relexxii®
F/Q/D
Ritalin®
Sunosi™
Vyvanse® chewable tablet
Wakix®
Xelstrym™
Zenzedi®
• PA required for initiation of CNS Stimulant for patients currently on a
benzodiazepine
DOSE OPTIMIZATION (DO)
• See Dose Optimization Chart for affected drugs and strengths
FREQUENCY/QUANTITY/DURATION (F/Q/D)
• Quantity limits based on daily dosage as determined by FDA labeling
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 21
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
IV. Central Nervous System
Movement Disorder Agents
CC
Austedo®
Austedo® XR
1
Austedo® XR titration pack
1
Ingrezza®
Ingrezza® Sprinkle
Ingrezza® titration pack
tetrabenazine
Xenazine®
CLINICAL CRITERIA (CC)
• Confirm diagnosis for an FDA-approved or compendia-supported
indication
Multiple Sclerosis Agents
Avonex®
Copaxone® 20 mg/mL
BLTG
dimethyl fumarate DR
Extavia®
1
fingolimod (gen Gilenya®)
Kesimpta®
1
teriflunomide (gen Aubagio®)
Aubagio®
Bafiertam™
Betaseron®
2
Copaxone® 40 mg/mL
Gilenya®
glatiramer
Mavenclad®
Mayzent®
Plegridy®
Ponvory™
F/Q/D
Rebif®
Rebif® Rebidose®
Tascenso ODT™
Tecfidera®
Vumerity®
Zeposia®
CC, ST
CLINICAL CRITERIA (CC)
• Zeposia® (ozanimod): Confirm diagnosis for FDA- or compendia-supported
use
STEP THERAPY (ST)
• Zeposia® (ozanimod): For an indication of Ulcerative Colitis
− Trial of a non-specific anti-inflammatory drug such as an
aminosalicylate or immunosuppressant, or a disease-modifying anti-
rheumatic drug (DMARD), and;
− Trial of a preferred systemic immunomodulator
FREQUENCY/QUANTITY/DURATION (F/Q/D)
• Ponvory™ (ponesimod) starter pack; maximum quantity is 14, no refills
• Ponvory™ (ponesimod); maintenance limited to a 30-day supply
Non-Ergot Dopamine Receptor Agonists
pramipexole
ropinirole
Mirapex ER®
Neupro®
pramipexole ER
ropinirole ER
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 22
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
IV. Central Nervous System
Other Agents for Attention Deficit Hyperactivity Disorder (ADHD)
CC
atomoxetine
DO
clonidine ER
guanfacine ER
DO
Intuniv®
DO
Qelbree™
Strattera®
DO
CLINICAL CRITERIA (CC)
• Confirm diagnosis for an FDA-approved or compendia-supported
indication for beneficiaries < 18 years of age.
• Prior authorization is required for initial prescriptions for non-stimulant
therapy for beneficiaries less than 6 years of age
DOSE OPTIMIZATION (DO)
• See Dose Optimization Chart for affected strengths
Sedative Hypnotics/Sleep Agents
F/Q/D
estazolam
CC
eszopiclone
ramelteon (gen Rozerem®)
temazepam 15 mg, 30 mg
CC
zolpidem tablet
CC
zolpidem ER
CC
Ambien®
CC
Ambien CR®
CC
Belsomra®
Dayvigo™
Doral®
CC
doxepin
Edluar®
CC
flurazepam
CC
Halcion®
CC
Lunesta®
DO
quazepam
CC
(gen Doral®)
Quviviq™
Restoril®
CC
Rozerem®
temazepam 7.5 mg, 22.5 mg
CC
triazolam
CC
zaleplon
zolpidem sublingual, capsule
CC
DOSE OPTIMIZATION (DO)
• See Dose Optimization Chart for affected strengths
CLINICAL CRITERIA (CC)
• Zolpidem products: Confirm dosage is consistent with FDA labeling for
initial prescriptions
• Benzodiazepine Agents (estazolam, flurazepam, Halcion®, Restoril®,
temazepam, triazolam):
− Confirm diagnosis of FDA-approved or compendia-supported
indication
− PA required for initiation of benzodiazepine therapy in patients
currently on opioid or oral buprenorphine therapy
− PA required for any additional benzodiazepine prescription in
patients currently on benzodiazepine therapy
− PA required when greater than a 14-day supply of a benzodiazepine
is prescribed for someone on a CNS stimulant
FREQUENCY/QUANTITY/DURATION (F/Q/D)
• Frequency and duration limits for the following products:
− For non-zaleplon and non-benzodiazepine containing products:
o 30 dosage units per fill/1 dosage unit per day/30 days
− For zaleplon-containing products:
o 60 dosage units per fill/2 dosage units per day/30 days
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 23
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
IV. Central Nervous System
− Duration limit equivalent to the maximum recommended duration:
o 180 days for immediate-release zolpidem (Ambien®, Edluar®)
products
o 180 days for eszopiclone and ramelteon (Rozerem®) products
o 180 days for lemborexant (Dayvigo™)
o 168 days for zolpidem ER (Ambien CR®) products
o 90 days for daridorexant (Quviviq™)
o 90 days for suvorexant (Belsomra®)
o 90 days for doxepin
o 30 days for zaleplon (Sonata®) products
o 30 days for benzodiazepine agents (estazolam, Halcion®,
Restoril®, temazepam, triazolam) for the treatment of insomnia
Additional/Alternate parameters:
• For patients naïve to non-benzodiazepine sedative hypnotics (NBSH): First-
fill duration and quantity limit of 10 dosage units as a 10-day supply,
except for zaleplon-containing products which the quantity limit is 20
dosage units as a 10-day supply
Selective Serotonin Reuptake Inhibitors (SSRIs)
citalopram tablet, solution
escitalopram tablet
fluoxetine capsule, solution
paroxetine tablet
sertraline tablet, concentrate
vilazodone (gen Viibryd®)
Celexa®
citalopram capsule
escitalopram solution
fluoxetine tablet
fluoxetine DR weekly
fluvoxamine
CC
fluvoxamine ER
CC
Lexapro®
DO
paroxetine capsule
paroxetine CR
paroxetine suspension
Paxil®
Paxil CR®
Pexeva®
DOSE OPTIMIZATION (DO)
• See Dose Optimization Chart for affected strengths
CLINICAL CRITERIA (CC)
• Clinical editing will allow patients currently stabilized on fluvoxamine or
fluvoxamine ER to continue to receive that agent without PA
• Clinical editing to allow patients with a diagnosis of Obsessive-Compulsive
Disorder (OCD) to receive fluvoxamine and fluvoxamine ER without prior
authorization
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 24
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
IV. Central Nervous System
Prozac®
sertraline capsule
Trintellix®
DO
Viibryd®
DO
Zoloft®
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
duloxetine 20 mg, 30 mg, 60 mg (gen
Cymbalta®)
venlafaxine
venlafaxine ER capsule
Cymbalta®
desvenlafaxine ER
desvenlafaxine succinate ER
DO
Drizalma Sprinkle™
duloxetine 40 mg
Effexor XR®
DO
Fetzima®
Pristiq®
DO
Savella®
venlafaxine ER tablet
DOSE OPTIMIZATION (DO)
• See Dose Optimization Chart for affected strengths
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 25
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
V. Dermatologic Agents
Acne Agents, Topical
adapalene/benzoyl peroxide (gen
Epiduo®)
adapalene cream
adapalene OTC gel
Retin-A® cream
CC, BLTG
tazarotene cream
CC
tretinoin gel (gen Avita, Retin-A)
CC
adapalene Rx gel, gel pump
adapalene/benzoyl peroxide (gen
Epiduo® Forte)
Altreno®
CC
Arazlo™
CC
Atralin®
CC
Avita®
CC
Cabtreo™
clindamycin/tretinoin
CC
dapsone
Fabior®
CC
Retin-A® gel
CC
Retin-A Micro®
CC
tazarotene foam (gen Fabior®)
CC
tazarotene gel
CC
tretinoin cream, gel
CC
(gen Atralin)
tretinoin micro
CC
Winlevi®
Ziana®
CC
CLINICAL CRITERIA
• Confirm diagnosis of FDA-approved, compendia-supported, and Medicaid-
covered indication
Actinic Keratosis Agents
diclofenac 3% gel
fluorouracil solution
fluorouracil 0.5% cream (gen Carac®)
fluorouracil 5% cream (gen Efudex®
cream)
imiquimod (gen Aldara®)
Carac®
Efudex®
imiquimod (gen Zyclara)
Zyclara®
Antibiotics – Topical
mupirocin ointment
Centany®
mupirocin cream
Xepi™
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 26
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
V. Dermatologic Agents
Anti-Fungals – Topical
ciclopirox cream, suspension, shampoo
ciclopirox 8% solution
clotrimazole OTC
clotrimazole Rx
clotrimazole/betamethasone cream
ketoconazole cream
ketoconazole 2% shampoo
miconazole OTC
nystatin cream, ointment, powder
nystatin/triamcinolone
terbinafine OTC
tolnaftate OTC
Alevazol OTC
butenafine
Ciclodan® cream
ciclopirox gel
clotrimazole/betamethasone lotion
econazole
Ertaczo®
Extina®
Jublia®
ketoconazole foam
Loprox® cream, suspension
luliconazole
Luzu®
miconazole/zinc/petrolatum (gen
Vusion®)
F/Q/D
naftifine
Naftin®
oxiconazole
Oxistat®
tavaborole
Vusion®
F/Q/D
FREQUENCY/QUANTITY/DURATION (F/Q/D)
• Vusion® 50 gm ointment –Maximum 100 grams in a 90-day time period
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 27
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
V. Dermatologic Agents
Anti-Infectives – Topical
clindamycin solution, gel, lotion, swab
clindamycin/benzoyl peroxide (gen
Duac®)
erythromycin solution, gel
Acanya®
Benzamycin®
Cleocin T®
Clindagel®
clindamycin phos gel (gen Clindagel®)
clindamycin foam
clindamycin/benzoyl peroxide (gen
BenzaClin®)
clindamycin/benzoyl peroxide (gen
Onexton®)
clindamycin/benzoyl peroxide (gen
Acanya®)
erythromycin swab
erythromycin/benzoyl peroxide
Evoclin®
Neuac®
Onexton®
Anti-Virals – Topical
acyclovir cream
docosanol (gen Abreva®)
acyclovir ointment
Denavir®
penciclovir (gen Denavir®)
Xerese®
Zovirax® cream, ointment
Immunomodulators – Topical
CC
Eucrisa®
pimecrolimus
tacrolimus
Elidel®
Opzelura®
Protopic®
CLINICAL CRITERIA
• Confirm diagnosis of FDA-approved, compendia-supported, and Medicaid-
covered indication
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 28
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
V. Dermatologic Agents
Psoriasis Agents – Topical
calcipotriene cream, ointment, scalp
solution
calcipotriene foam (gen Sorilux®)
calcipotriene/betamethasone
dipropionate (gen Taclonex®)
calcitriol ointment (gen Vectical®)
Duobrii™
Enstilar®
Sorilux®
Taclonex®
Vtama®
Zoryve™
Rosacea Agents, Topical
CC
azelaic acid
metronidazole cream, gel
Finacea®
Ivermectin
metronidazole gel pump, lotion
Noritate®
Rosadan®
CLINICAL CRITERIA
Confirm diagnosis of FDA-approved, compendia-supported, and Medicaid-
covered indication
Steroids, Topical – Low Potency
hydrocortisone acetate OTC
hydrocortisone acetate Rx
alclometasone
Derma-Smoothe/FS®
desonide
fluocinolone oil
Hydroxym™
Texacort®
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 29
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
V. Dermatologic Agents
Steroids, Topical – Medium Potency
fluocinolone acetonide solution
fluticasone propionate cream,
ointment
hydrocortisone valerate cream
mometasone furoate
Beser lotion
betamethasone valerate foam
clocortolone
Cloderm®
fluocinolone acetonide cream,
ointment
flurandrenolide
fluticasone propionate lotion
hydrocortisone butyrate cream, lotion,
ointment, solution
hydrocortisone valerate ointment
Locoid®
Locoid Lipocream®
Pandel®
prednicarbate
Synalar®
Steroids, Topical – High Potency
betamethasone dipropionate lotion,
cream, ointment
betamethasone dipropionate
augmented cream, ointment, lotion
betamethasone valerate cream,
ointment
fluocinonide cream, ointment, solution
triamcinolone acetonide
ApexiCon-E®
betamethasone dipropionate
augmented gel
betamethasone valerate lotion
desoximetasone
diflorasone
Diprolene®
fluocinonide gel, emollient
halcinonide cream (gen Halog®)
Halog® cream, solution, ointment
Kenalog®
Topicort®
triamcinolone spray
Vanos®
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 30
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
V. Dermatologic Agents
Steroids, Topical – Very High Potency
clobetasol cream, emollient, gel,
ointment, solution
halobetasol cream, ointment
Bryhali™
clobetasol foam, lotion, spray,
shampoo
Clobex®
halobetasol foam
Impeklo™
Lexette™ foam
Olux®
Temovate®
Ultravate®
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 31
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
VI. Endocrine and Metabolic Agents
Anabolic Steroids – Topical
CDRP, F/Q/D
testosterone gel packets (gen
Vogelxo®)
1
testosterone gel pump (gen Androgel)
Androderm®
AndroGel® pump
Fortesta®
Natesto®
Testim®
testosterone gel packets (gen
AndroGel®)
2
Vogelxo®
CLINICAL DRUG REVIEW PROGRAM (CDRP)
• For diagnosis of hypogonadotropic or primary hypogonadism:
− Requires documented low testosterone concentration with two tests
prior to initiation of therapy.
− Requires documented testosterone therapeutic concentration to
confirm response after initiation of therapy.
• For diagnosis of delayed puberty:
− Requires documentation that growth hormone deficiency has been
ruled out prior to initiation of therapy.
The Anabolic Steroid fax form can be found at:
https://newyork.fhsc.com/downloads/providers/NYRx_CDRP_PA_Worksh
eet_Prescribers_Anabolic_Steroids.pdf
For diagnosis of gender dysphoria, see Hormone Replacement Therapy for
Treatment of Gender Dysphoria coverage in the DUR section of this
document
FREQUENCY/QUANTITY/DURATION (F/Q/D)
• Limitations for anabolic steroid products based on approved FDA labeled
daily dosing and documented diagnosis:
− Duration limit of 6 months for delayed puberty
Biguanides
glipizide/metformin
glyburide/metformin
Glumetza®
BLTG
metformin HCl
metformin ER (gen Glucophage XR®)
metformin solution (gen Riomet®)
metformin 625mg tablets
metformin ER
DO
(gen Fortamet®,
Glumetza®)
Riomet®
Riomet ER™
DOSE OPTIMIZATION (DO)
• See Dose Optimization Chart for affected strengths
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 32
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
VI. Endocrine and Metabolic Agents
Bisphosphonates – Oral
alendronate
Actonel®
Atelvia®
Binosto®
Fosamax®
Fosamax® Plus D
ibandronate
risedronate
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
alogliptin
alogliptin/metformin
Glyxambi®
Janumet®
Janumet® XR
Januvia®
DO
Jentadueto®
Jentadueto® XR
Kazano®
Kombiglyze® XR
BLTG
Nesina®
Onglyza®
DO, BLTG
Oseni®
BLTG
Tradjenta®
alogliptin/pioglitazone
Qtern®
saxagliptin (gen Onglyza®)
saxagliptin/metformin (gen
Kombiglyze® XR)
sitagliptin (gen Zituvio™)
Steglujan®
Zituvio™
DOSE OPTIMIZATION (DO)
• See Dose Optimization Chart for affected strengths
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 33
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
VI. Endocrine and Metabolic Agents
Glucagon Agents
Baqsimi®
glucagon vial
glucagon HCl emergency kit (Fresenius)
Gvoke®
pen, syringe, vial
Zegalogue® pen, syringe
glucagon emergency kit (Eli Lilly,
Amphastar)
Glucagon-like Peptide-1 (GLP-1) Agonists
CC
Byetta®
Ozempic®
Trulicity®
Victoza®
BLTG
Bydureon® BCise™
liraglutide (gen Victoza®)
Mounjaro®
Rybelsus®
Soliqua®
Xultophy®
CLINICAL CRITERIA (CC)
• Confirm diagnosis of FDA-approved, compendia-supported, and Medicaid-
covered indication
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 34
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
VI. Endocrine and Metabolic Agents
Glucocorticoids – Oral
budesonide EC, DR
dexamethasone tablet
hydrocortisone
methylprednisolone dose-pack
prednisolone solution
prednisone dose-pack, tablet
Agamree®
Alkindi® Sprinkle
budesonide ER
Cortef®
cortisone
deflazacort (gen Emflaza®)
dexamethasone elixir, solution
dexamethasone intensol
Emflaza®
Eohilia™
Hemady™
Medrol® dose-pack, tablet
methylprednisolone 4 mg, 8 mg, 16 mg,
32 mg
Millipred®
Millipred® DP
prednisolone ODT
prednisolone tablet (gen Millipred®)
prednisone intensol, solution
Rayos®
TaperDex™
Uceris®
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 35
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
VI. Endocrine and Metabolic Agents
Growth Hormones
CC
Genotropin®
Norditropin®
Humatrope®
Ngenla™
Nutropin AQ®
Omnitrope®
Saizen®
Skytrofa®
Sogroya®
Zomacton®
CLINICAL CRITERIA (CC)
• Confirm diagnosis of FDA-approved or compendia-supported indication
• For Diagnosis of Growth Hormone Deficiency (GHD) or Short for
Gestational Age (SGA):
− Prior to initiating growth hormone treatment, documentation of a
recommended GHD diagnostic and / or laboratory test (e.g.,
provocative test and / or IGF-1 test)
− Continuation of GH treatment, documentation of a recommended
GHD laboratory test annually (e.g., IGF-1 test) and documentation of
positive treatment response
Insulin – Long-Acting
insulin glargine solostar, vial (gen
Lantus® Solostar®, vial)
Lantus® Solostar®, vial
Levemir®
Basaglar®
Basaglar® Tempo™
insulin degludec vial, pen (gen Tresiba)
insulin glargine max solostar (gen
Toujeo® Max Solostar®)
insulin glargine solostar (gen Toujeo®
Solostar®)
insulin glargine-YFGN: vial, pen
Rezvoglar™
Semglee®-YFGN: vial, pen
Toujeo® Solostar®
Toujeo® Max Solostar®
Tresiba®
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 36
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
VI. Endocrine and Metabolic Agents
Insulin – Mixes
Humalog® 50/50 Mix: pen and vial
Humalog® 75/25 Mix: vial
insulin lispro 75/25 mix: pen (gen
Humalog® Mix)
insulin aspart prot/insulin aspart: vial,
pen (gen Novolog)
Humalog® 75/25 mix: pen
Novolog® Mix: vial, pen
Insulin – Rapid-Acting
Apidra®
Humalog® Jr. 100 U/mL Kwikpen
Humalog® 100 U/mL vial, pen,
cartridge, Tempo™
insulin aspart (gen Novolog®) cartridge,
vial, pen
insulin lispro (gen Humalog® U100) vial,
pen
insulin lispro junior (gen Humalog® Jr.)
Novolog® cartridge, vial, FlexPen
Admelog®
Afrezza®
Fiasp® Penfill, FlexTouch, Pumpcart,
vial
Humalog® 200 U/mL
Lyumjev®
Lyumjev® Tempo™
Pancreatic Enzymes
Creon®
Zenpep®
Pertzye®
Viokace®
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 37
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
VI. Endocrine and Metabolic Agents
Sodium Glucose Co-Transporter 2 (SGLT2) Inhibitors
Farxiga®
BLTG
Invokamet®
Invokamet® XR
Invokana®
Jardiance®
Synjardy®
Synjardy® XR
Trijardy® XR
Xigduo® XR
BLTG
dapagliflozin (gen Farxiga®)
dapagliflozin/metformin (gen Xigduo®
XR)
Inpefa™
Segluromet®
Steglatro®
Thiazolidinediones (TZDs)
pioglitazone
ACTOplus Met®
Actos®
DO
Duetact®
pioglitazone/glimepiride
pioglitazone/metformin
DOSE OPTIMIZATION (DO)
• See Dose Optimization Chart for affected strengths
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
VII. Gastrointestinal
Anti-Emetics
aprepitant pack
Diclegis®
CC
doxylamine succ/pyridoxine (gen
Diclegis®)
CC
ondansetron ODT, solution, tablet
Akynzeo®
Anzemet®
aprepitant capsule
Bonjesta®
CC
Emend® capsule, powder packet, TriPack
granisetron tablet
Sancuso®
CLINICAL CRITERIA (CC)
• doxylamine succ/pyridoxine (Diclegis®, Bonjesta®): Confirm diagnosis of
FDA-approved or compendia-supported indication
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 38
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
VII. Gastrointestinal
Gastrointestinal Antibiotics
metronidazole tablet
neomycin
vancomycin capsule, solution
Dificid®
Firvanq®
Flagyl®
Likmez™
metronidazole capsule
nitazoxanide
paromomycin
tinidazole
Vancocin®
Xifaxan®
CC,
ST, F/Q/D
CLINICAL CRITERIA (CC)
• Xifaxan®: Confirm diagnosis of FDA-approved or compendia-supported
indication
STEP THERAPY (ST)
• Xifaxan®: Requires trial of a fluoroquinolone antibiotic or azithromycin
before Xifaxan® for treatment of Traveler’s Diarrhea
QUANTITY LIMITS:
Xifaxan®:
• Irritable bowel syndrome with diarrhea (550 mg tablets) – 42 tablets per
30 days (Dose = 550 mg three times a day for 14 days)
− Maximum of 42 days’ supply (126 units) per 365 days (3 rounds of
therapy).
• Small Intestine Bacterial Overgrowth (550mg tablets) - 42 tablets per 30
days (Dose = 550mg three times a day for 10-14 days);
− Maximum of 28 days’ supply (84 units) per 365 days (2 rounds of
therapy).
Helicobacter pylori Agents
Pylera®
BLTG
bismuth/metronidazole/tetracycline (gen
Pylera®)
lansoprazole/amoxicillin/clarithromycin
Omeclamox-Pak®
Talicia®
Voquezna® Dual Pak
Voquezna® Triple Pak
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 39
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
VII. Gastrointestinal
Proton Pump Inhibitors (PPIs)
F/Q/D
esomeprazole magnesium Rx capsule
lansoprazole capsule (Rx, OTC)
lansoprazole OTC solutab
omeprazole Rx
pantoprazole tablet
Protonix suspension
BLTG
rabeprazole
Zegerid® Rx
BLTG
Aciphex®
dexlansoprazole (gen Dexilant®)
Dexilant®
DO, 2
esomeprazole magnesium tablet OTC
esomeprazole capsules OTC
esomeprazole suspension
Konvomep™
lansoprazole Rx solutab
Nexium® RX
DO
omeprazole OTC
omeprazole/sodium bicarbonate Rx
pantoprazole suspension
Prevacid® OTC
Prevacid®
Rx
DO
Prilosec® Rx
Protonix® tablet
DOSE OPTIMIZATION (DO)
• See Dose Optimization Chart for affected strengths
FREQUENCY/QUANTITY/DURATION (F/Q/D)
• Quantity limits:
− Once daily dosing for:
o GERD
o erosive esophagitis
o healing and maintenance of duodenal/gastric ulcers (including
NSAID-induced)
o prevention of NSAID-induced ulcers
− Twice daily dosing for:
o hypersecretory conditions
o Barrett's esophagitis
o H. pylori
o refractory GERD
• Duration limits:
− 90 days for:
o GERD
− 365 days for:
o Maintenance treatment of duodenal ulcers, or erosive
esophagitis
− 14 days for:
o H. pylori
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 40
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
VII. Gastrointestinal
Sulfasalazine Derivatives
Apriso®
BLTG
mesalamine DR (gen Lialda®)
Pentasa®
BLTG
sulfasalazine DR
sulfasalazine IR
Azulfidine®
Azulfidine Entab®
balsalazide
Colazal®
Delzicol®
Dipentum®
Lialda®
mesalamine DR (gen Delzicol®)
mesalamine ER (gen Apriso®)
mesalamine ER (gen Pentasa®)
mesalamine DR
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 41
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
VIII. Hematological Agents
Anticoagulants – Injectable
F/Q/D
enoxaparin sodium
Fragmin® vial
Arixtra®
CC
fondaparinux
CC
Fragmin® syringe
Lovenox®
CLINICAL CRITERIA (CC)
• For patients requiring > 30 days of therapy: Require confirmation of FDA-
approved or compendia-supported indication
• Arixtra® (fondaparinux) Clinical editing to allow patients with a diagnosis
of Heparin Induced Thrombocytopenia (HIT) to receive therapy without
prior authorization.
FREQUENCY/QUANTITY/DURATION (F/Q/D)
• Duration Limit: No more than 30 days for members initiating therapy
Anticoagulants – Oral
Eliquis®
Pradaxa® capsule
BLTG
warfarin
Xarelto® tablet
DO
dabigatran (gen Pradaxa®)
Pradaxa® pellet pack
Savaysa®
Xarelto® dose pack, suspension
DOSE OPTIMIZATION (DO)
• See Dose Optimization Chart for affected strengths
Colony Stimulating Factors
Neupogen®
Nyvepria™
Fylnetra®
Fulphila™
Granix®
Leukine®
Neulasta®
Nivestym™
Releuko™
Rolvedon®
Stimufend®
Udenyca®
Zarxio®
Ziextenzo®
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 42
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
VIII. Hematological Agents
Erythropoiesis Stimulating Agents (ESAs)
CC
Aranesp®
Epogen®
Retacrit®
Mircera®
Procrit®
CLINICAL CRITERIA (CC)
• Confirm diagnosis for FDA- or compendia-supported uses
Hemophilia Agents – Factor VIII
Advate®
Adynovate®
Afstyla®
Altuviiio
™1
Eloctate®
Esperoct®
Hemofil® M
Humate-P®
Jivi®
Koate®
Kogenate® FS
Kovaltry®
Novoeight®
Nuwiq®
Obizur®
Recombinate™
Xyntha®
Xyntha® Solofuse
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 43
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
VIII. Hematological Agents
Hemophilia Agents – Factor IX
AlphaNine® SD
Alprolix®
BeneFIX®
Idelvion®
Ixinity®
Profilnine®
Rebinyn®
Rixubis®
N/A
Hemophilia Agents – Other
Alphanate® (von Willebrand
factor/Factor VIII)
Coagadex® (Factor X)
Corifact® (Factor XIII)
Feiba® NF (activated prothrombin
complex)
Hemlibra® (emicizumab-kxwh)
Novoseven® RT (Factor VIIa)
Sevenfact® (Factor VIIa-jncw)
Tretten® (Factor XIII)
Vonvendi® (von Willebrand factor)
Wilate® (von Willebrand factor/Factor
VIII)
N/A
Platelet Inhibitors
Brilinta®
clopidogrel
dipyridamole
dipyridamole/aspirin
Effient®
Plavix®
prasugrel
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 44
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
IX. Immunologic Agents
Immunomodulators – Systemic
CC, ST
Cosentyx®
Dupixent®
Enbrel®
Fasenra®
Humira®
Nucala®
Xolair®
Abrilada™ (adalimumab-AFZB)
Actemra® subcutaneous
adalimumab-AACF (gen Idacio®)
adalimumab-AATY (gen Yuflyma®)
adalimumab-ADAZ (gen Hyrimoz®)
adalimumab-ADBM (gen Cyltezo®)
adalimumab-FKJP (gen Hulio®)
adalimumab-RYVK (gen Simlandi®)
Adbry™
Amjevita™
Bimzelx®
Cibinqo™
Cimzia®
Cyltezo® (adalimumab-ADMB)
Entyvio pen®
Hadlima™
Hulio® (adalimumab-FKJP)
Hyrimoz® (adalimumab-ADAZ)
Idacio®
Ilumya®
Kevzara®
Kineret®
Olumiant®
Omvoh™ pen
Orencia® subcutaneous
Otezla®
Rinvoq™ ER
Siliq™
Simlandi®
Simponi®
CLINICAL CRITERIA (CC)
• Confirm diagnosis for FDA- or compendia-supported uses
STEP THERAPY (ST)
For indications not specified below
• Trial of a non-specific anti-inflammatory drug such as an aminosalicylate or
immunosuppressant, or a disease-modifying anti-rheumatic drug (DMARD)
• Trial of a TNF inhibitor prior to treatment with a JAK inhibitor
INDICATION-SPECIFIC REQUIREMENTS:
• Asthma:
− history and concurrent use of a corticosteroid
• Nasal polyps:
− history and concurrent use of an intranasal corticosteroid
• Atopic dermatitis:
− Trial with a topical prescription product for a duration of at least 3
months.
− For JAK inhibitors: Trial of topical prescription product and systemic
product for a combined duration of at least 6 months.
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 45
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
IX. Immunologic Agents
Immunomodulators – Systemic
CC, ST
Skyrizi®
Skyrizi® On-Body
Sotyktu™
Spevigo®
Stelara®
Taltz®
Tezspire® pen
Tremfya®
Velsipity™
Xeljanz®
Xeljanz® XR
Yuflyma®
Yusimry™
Zymfentra™
Immunosuppressives, Oral
azathioprine
CellCept® suspension
BLTG
cyclosporine softgel, capsule
cyclosporine modified capsule, solution
mycophenolic acid
mycophenolate mofetil capsule, tablet
Rapamune® solution
Rapamune® tablet
sirolimus solution, tablet
tacrolimus
Astagraf XL®
Azasan®
CellCept® capsule, tablet
Envarsus XR®
everolimus (gen Zortress®)
Imuran®
Lupkynis™
CC, F/Q/D, ST
mycophenolate mofetil suspension
Myfortic®
Neoral®
Prograf®
Sandimmune® capsule, solution
Zortress®
CLINICAL CRITERIA (CC)
• Lupkynis™ (voclosporin) – Confirm diagnosis for FDA- or compendia-
supported uses
STEP THERAPY (ST)
• Trial of mycophenolate prior to Lupkynis™
FREQUENCY/QUANTITY/DURATION (F/Q/D)
• Lupkynis™ limited to 30-day supply
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 46
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
X. Miscellaneous Agents
Progestins (for Cachexia)
megestrol acetate suspension
megestrol 625 mg/5 mL suspension
Epinephrine – Self-injected
EpiPen®
BLTG
EpiPen Jr.®
BLTG
Auvi-Q®
epinephrine (gen Adrenaclick®)
epinephrine (gen EpiPen®)
epinephrine (gen EpiPen Jr.®)
Symjepi®
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 47
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
XI. Musculoskeletal Agents
Skeletal Muscle Relaxants
baclofen tablet
chlorzoxazone 500 mg
cyclobenzaprine 5 mg, 10 mg tablet
dantrolene
methocarbamol
orphenadrine ER
tizanidine tablet
Amrix®
baclofen 15mg tablet
baclofen solution
baclofen suspension (gen Fleqsuvy™)
carisoprodol
ST, F/Q/D
carisoprodol compound
ST, F/Q/D
carisoprodol compound/codeine
CC, ST,
F/Q/D
chlorzoxazone (gen Lorzone) 375 mg,
750 mg
cyclobenzaprine 7.5 mg
cyclobenzaprine ER capsule (gen Amrix)
Dantrium®
Fexmid®
Fleqsuvy™
Lorzone®
Lyvispah™
metaxalone
orphenadrine-aspirin-caffeine
Soma®
ST, F/Q/D
Soma® 250
ST, F/Q/D
tizanidine capsule
Zanaflex®
CLINICAL CRITERIA (CC)
For carisoprodol/codeine products:
• Limited to a total of 4 opioid prescriptions every 30 days; exemption for
diagnosis of cancer or sickle cell disease
• Medical necessity rationale for opioid therapy is required for patients on
established opioid dependence therapy
• PA required for initiation of opioid therapy in patients currently on
benzodiazepine therapy
• PA required for any codeine containing products in patients < 12 years
STEP THERAPY (ST)
• Trial with 1 analgesic and 2 skeletal muscle relaxants prior to use of
carisoprodol containing products
FREQUENCY/QUANTITY/DURATION (F/Q/D)
• Carisoprodol – Maximum 4 units per day, 21-day supply
• Carisoprodol combinations – Maximum 8 units per day, 21-day supply
(not to exceed the 84 cumulative units per year limit)
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 48
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
XII. Ophthalmics
Alpha-2 Adrenergic Agonists (for Glaucoma) – Ophthalmic
Alphagan P® 0.1%
BLTG
Alphagan P® 0.15%
BLTG
brimonidine 0.2%
Simbrinza®
apraclonidine
brimonidine 0.1% (gen Alphagan P®)
brimonidine 0.15% (gen Alphagan P®)
Iopidine®
Antibiotics – Ophthalmic
bacitracin/polymyxin B
erythromycin
gentamicin
Natacyn®
neomycin/gramicidin/polymyxin
polymyxin/trimethoprim
sulfacetamide solution
tobramycin
Azasite®
bacitracin
neomycin/bacitracin/polymyxin
sulfacetamide ointment
Tobrex®
Antibiotics/Steroid Combinations – Ophthalmic
neomycin/polymyxin/dexamethasone
sulfacetamide/prednisolone
TobraDex® ointment
tobramycin/dexamethasone suspension
Maxitrol®
neomycin / bacitracin/polymyxin /HC
neomycin/polymyxin/HC
TobraDex® ST
Zylet®
Antihistamines – Ophthalmic
azelastine
ketotifen OTC
olopatadine OTC
bepotastine (gen Bepreve®)
Bepreve®
epinastine
Lastacaft®
olopatadine Rx
Pataday®
Zaditor® OTC
Zerviate™
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 49
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
XII. Ophthalmics
Anti-inflammatories/Immunomodulators – Ophthalmic
CC
Eysuvis®
F/Q/D
Restasis®
BLTG
Restasis MultiDose®
Xiidra®
Cequa®
cyclosporine (gen Restasis®)
Miebo™
Tyrvaya™
Verkazia®
Vevye®
CLINICAL CRITERIA (CC)
• Diagnosis documentation required to justify utilization as a first line
agent or attempt treatment with an artificial tear, gel, or ointment.
FREQUENCY/QUANTITY/DURATION (F/Q/D)
• Eysuvis® max duration: 2 weeks
Beta Blockers – Ophthalmic
betaxolol
Betoptic S®
carteolol
Combigan®
BLTG
Istalol®
BLTG
levobunolol
timolol maleate gel
Betimol®
brimonidine/timolol (gen Combigan®)
timolol maleate (gen Timoptic®
Ocudose®)
timolol maleate solution (gen Istalol®)
Timoptic® Ocudose®
Fluoroquinolones – Ophthalmic
ciprofloxacin
moxifloxacin (gen Vigamox®)
ofloxacin
Besivance®
Ciloxan®
gatifloxacin
moxifloxacin (gen Moxeza®)
Ocuflox®
Vigamox®
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 50
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
XII. Ophthalmics
Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) – Ophthalmic
diclofenac
flurbiprofen
ketorolac
ketorolac LS
Acular®
Acular LS®
Acuvail®
bromfenac
BromSite®
Ilevro®
2
Nevanac®
Prolensa®
Prostaglandin Agonists – Ophthalmic
latanoprost
bimatoprost
Iyuzeh™
Lumigan®
Rocklatan™
tafluprost (gen Zioptan®)
Travatan Z®
travoprost (gen Travatan Z®)
Xalatan®
Xelpros™
Vyzulta™
Zioptan®
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 51
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
XIII. Otics
Fluoroquinolones – Otic
Cipro HC®
ciprofloxacin/dexamethasone (gen
Ciprodex®)
ofloxacin
Ciprodex®
ciprofloxacin
ciprofloxacin/fluocinolone (gen
Otovel™)
Otovel™
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 52
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
XIV. Renal and Genitourinary
Alpha Reductase Inhibitors for BPH
finasteride
Avodart®
dutasteride
dutasteride/tamsulosin
Entadfi™
Proscar®
Antihyperuricemics
allopurinol 100 mg, 300 mg
colchicine tablet
febuxostat
probenecid
probenecid/colchicine
allopurinol 200 mg
colchicine capsule
Colcrys
Gloperba®
Mitigare®
Uloric®
Zyloprim®
Cystine Depleting Agents
CC
Cystagon®
Procysbi®
ST
CLINICAL CRITERIA (CC)
• Confirm diagnosis of FDA-approved or compendia-supported indication
Electrolyte Depleters
Lokelma®
sodium polystyrene
Veltassa®
Phosphate Binders/Regulators
calcium acetate
sevelamer carbonate powder, tablet
(gen Renvela)
Auryxia™
Fosrenol®
lanthanum carbonate
Renvela® tablet, powder pack
sevelamer HCl (gen Renagel)
2
Velphoro®
Xphozah®
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 53
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
XIV. Renal and Genitourinary
Selective Alpha Adrenergic Blockers
alfuzosin
tamsulosin
Flomax®
Rapaflo®
silodosin
Urinary Tract Antispasmodics
fesoterodine ER (gen Toviaz®)
Myrbetriq®
DO, BLTG
oxybutynin
oxybutynin ER
DO
solifenacin
Toviaz®
DO
darifenacin
Detrol®
Detrol LA®
DO
flavoxate
Gelnique®
Gemtesa®
mirabegron (gen Myrbetriq®)
Myrbetriq® solution
F/Q/D
Oxytrol®
tolterodine
tolterodine ER
trospium
trospium ER
Vesicare®
DO
Vesicare® LS
DOSE OPTIMIZATION (DO)
• See Dose Optimization Chart for affected strengths
FREQUENCY/QUANTITY/DURATION (F/Q/D)
• Myrbetriq® solution; limited to a 30-day supply
Urea Cycle Disorders
Buphenyl® powder, tablet
Carbaglu®
BLTG
Olpruva™
Pheburane®
Ravicti®
sodium phenylbutyrate powder, tablet
(gen Buphenyl®)
carglumic acid
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 54
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
XIV. Renal and Genitourinary
Uterine Disorder Treatments
F/Q/D
Myfembree®
Oriahnn®
Orilissa®
LIFETIME QUANTITY LIMIT:
• 24 months cumulative use
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 55
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
XV. Respiratory
Anticholinergics / COPD Agents
Anoro Ellipta®
Atrovent HFA®
Bevespi® Aerosphere®
Combivent Respimat®
Incruse Ellipta®
ipratropium
ipratropium / albuterol
roflumilast (gen Daliresp®)
Spiriva® HandiHaler®
BLTG
Spiriva Respimat®
Stiolto Respimat®
Trelegy Ellipta®
Tudorza Pressair®
Breztri™ Aerosphere
Daliresp®
Duaklir® Pressair
tiotropium (gen Spiriva® Handihaler®)
Yupelri®
Antihistamines – Intranasal
azelastine
olopatadine
Patanase®
Antihistamines – Second Generation
cetirizine OTC tablet
cetirizine OTC syrup/solution 1 mg/
1 mL
fexofenadine OTC tablet
levocetirizine tablet
loratadine OTC
cetirizine OTC chewable
cetirizine OTC syrup/solution 5 mg/5 mL
cetirizine-D OTC
Clarinex®
Clarinex-D®
desloratadine (gen Clarinex®)
levocetirizine solution
loratadine-D OTC
Beta2 Adrenergic Agents – Inhaled Long-Acting
CC, F/Q/D
arformoterol (gen Brovana®)
formoterol (gen Perforomist®)
Serevent Diskus®
Brovana®
Perforomist®
Striverdi Respimat®
CLINICAL CRITERIA (CC)
• PA is required for all new long-acting beta agonist prescriptions for
beneficiaries under FDA- or compendia-supported age as indicated:
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 56
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
XV. Respiratory
Brovana® / arformoterol
≥ 18 years
Perforomist® / formoterol
≥ 18 years
Serevent Diskus®
≥ 4 years
Striverdi Respimat®
≥ 18 years
FREQUENCY/QUANTITY/DURATION (F/Q/D)
Maximum units per 30 days
Brovana® / arformoterol
60 units (1 carton of 60 vials or 120 mL)
Perforomist® / formoterol
60 units (1 carton of 60 vials or 120 mL)
Serevent Diskus®
1 diskus (60 blisters)
Striverdi Respimat®
1 unit (one cartridge and one Respimat inhaler)
Beta2 Adrenergic Agents – Inhaled Short-Acting
albuterol nebulizer solution
albuterol HFA (gen ProAir® HFA)
ProAir® Digihaler™
ProAir® RespiClick
Ventolin HFA®
BLTG
Xopenex HFA®
BLTG
Airsupra™
albuterol HFA (gen Ventolin HFA®)
levalbuterol solution
levalbuterol HFA
Corticosteroids – Inhaled
Alvesco®
Arnuity Ellipta®
Asmanex® Twisthaler
fluticasone HFA
Pulmicort® Flexhaler
ArmonAir® Digihaler®
Asmanex® HFA
fluticasone DISKUS
QVAR RediHaler®
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 57
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
XV. Respiratory
Corticosteroid/Beta2 Adrenergic Agent (Long-Acting) Combinations – Inhaled
CC, F/Q/D
Advair Diskus®
BLTG
Advair HFA®
BLTG
Dulera®
Symbicort®
BLTG
AirDuo® Digihaler®
AirDuo™ RespiClick®
Breo Ellipta®
budesonide/formoterol (gen Symbicort)
fluticasone-salmeterol (gen AirDuo™
RespiClick®)
fluticasone-salmeterol (gen Advair Diskus®)
fluticasone-salmeterol (gen Advair HFA™)
fluticasone-vilanterol (gen Breo Ellipta®)
CLINICAL CRITERIA (CC)
• PA is required for all new long-acting beta agonist prescriptions for
beneficiaries under FDA-or compendia-supported age as indicated:
Advair Diskus®
≥ 4 years
Advair HFA®
≥ 12 years
AirDuo™ RespiClick®
> 12 years
Dulera® 100 mcg and 200 mcg
≥ 12 years
Dulera® 50 mcg
≥ 4 years
fluticasone-salmeterol
> 4 years
budesonide-formoterol (Symbicort®) 80/4.5 mcg
≥ 4 years
budesonide-formoterol (Symbicort®) 160/4.5 mcg
≥ 12 years
fluticasone/vilanterol (Breo Ellipta®)
≥ 18 years
FREQUENCY/QUANTITY/DURATION (F/Q/D)
Advair Diskus®
One inhaler/diskus
every 30 days
Advair HFA®
AirDuo™ RespiClick®
fluticasone-salmeterol
fluticasone/vilanterol (Breo Ellipta®)
Budesonide/formoterol (Symbicort®)
Up to 8 inhalers every
180 days
Dulera®
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 58
Preferred Drugs
Non-Preferred Drugs
Prior Authorization/Coverage Parameters
XV. Respiratory
Corticosteroids – Intranasal
budesonide OTC
Dymista®
BLTG
fluticasone
fluticasone OTC
Nasonex® OTC
Omnaris®
triamcinolone OTC
Zetonna®
azelastine-fluticasone (gen Dymista®)
Beconase AQ®
CC
flunisolide
mometasone Rx, OTC
QNASL®
CC
Ryaltris®
Xhance™
CLINICAL CRITERIA (CC)
• Clinical consideration in regard to drug interactions will be given to
patients with HIV/AIDs diagnosis or antiretroviral therapy in history
Leukotriene Modifiers
montelukast tablet, chew tab
Accolate®
montelukast granules
Singulair®
zafirlukast
Revised: August 01, 2024
NYRx, the Medicaid Pharmacy Program Preferred Drug List
1 = Preferred as of 8/1/2024
2 = Non-Preferred as of 8/1/2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 59
NYS Medicaid NYRx Clinical Drug Review Program (CDRP)
The Clinical Drug Review Program (CDRP) is aimed at ensuring specific drugs are utilized in a medically appropriate manner.
Under the CDRP, certain drugs require prior authorization because there may be specific safety issues, public health concerns, the potential for fraud and abuse
or the potential for significant overuse and misuse.
Prior Authorization
Prior authorization for some drugs subject to the CDRP must be obtained through a representative at the clinical call center. For some drugs subject to the CDRP,
only prescribers, not their authorized agents, can initiate the prior authorization process.
Please be prepared to respond to a series of questions that identify prescriber, patient, and reason for prescribing drug, and to fax clinical documentation upon
request. Clinical guidelines for the CDRP as well as prior authorization worksheets are available online at https://newyork.fhsc.com/providers/CDRP_about.asp.
The following drugs are subject to the Clinical Drug Review Program:
• fentanyl mucosal agents: https://newyork.fhsc.com/providers/CDRP_fentanyl_mucosal_agents.asp
• palivizumab (Synagis®): https://newyork.fhsc.com/providers/CDRP_synagis.asp
• sodium oxybate products (Xyrem®, Xywav™): https://newyork.fhsc.com/providers/CDRP_xyrem.asp
• somatropin (Serostim®): https://newyork.fhsc.com/providers/CDRP_serostim.asp
The following drug classes are subject to the Clinical Drug Review Program and are also included on the Preferred Drug List:
Anabolic Steroids: https://newyork.fhsc.com/providers/CDRP_anabolic_steroids.asp
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 60
NYS Medicaid NYRx Drug Utilization Review (DUR) Program
Frequency/Quantity/Duration (F/Q/D) Program and Step Therapy parameters are implemented to ensure clinically appropriate and cost effective use of these
drugs and drug classes.
For additional Step Therapy and Frequency/Quantity/Duration parameters for drugs and drug classes that are also included on the Preferred Drug List (PDL), please
see pages 3 through 60.
Drug / Class Name
Step Therapy (ST) Parameters
Frequency / Quantity / Duration
(F/Q/D) Parameters
Additional / Alternate
Parameter(s)
Corticotropin (Acthar®, Cortrophin®)
Requires trial of first-line therapy for all
FDA-approved indications, other than
infantile spasms.
Note: It is first line therapy for infantile
spasms in children less than 2 years
of age – step therapy not required.
QUANTITY LIMITS:
• Infantile spasms – 30 mL (six 5 mL
vials)
• Multiple sclerosis – 35 mL (seven 5
mL vials)
DURATION LIMITS:
• Infantile spasms – 4 weeks;
indicated for < 2 years of age
• Multiple sclerosis – 5 weeks
• Rheumatic disorders – 5 weeks
• Dermatologic conditions –
5 weeks
• Allergic states (serum sickness) –
5 weeks
• Confirm diagnosis of FDA-
approved or compendia-
supported indication
• Not covered for diagnostic
purposes
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 61
Drug / Class Name
Step Therapy (ST) Parameters
Frequency / Quantity / Duration
(F/Q/D) Parameters
Additional / Alternate
Parameter(s)
Corticotropin (Acthar® Cortrophin®) (continued)
FDA Indication
First Line Therapy
• Multiple Sclerosis (MS)
exacerbations
• Polymyositis/ dermatomyositis
• Idiopathic nephrotic syndrome
• Systemic lupus erythematosus
(SLE)
• Nephrotic syndrome due to SLE
• Rheumatic disorders (specifically:
psoriatic arthritis, rheumatoid
arthritis, juvenile rheumatoid
arthritis, ankylosing spondylitis)
• Dermatologic diseases (specifically
Stevens-Johnson syndrome and
erythema multiforme)
• Allergic states (specifically serum
sickness)
• Ophthalmic diseases (keratitis,
iritis, iridocyclitis, diffuse posterior
uveitis/choroiditis, optic neuritis,
chorioretinitis, anterior segment
inflammation)
• Respiratory diseases (systemic
sarcoidosis)
• Corticosteroid or plasmapheresis
• Corticosteroid
• ACE Inhibitor, diuretic,
corticosteroid (and for refractory
patients: an immunosuppressive)
• Corticosteroid, antimalarial, or
cytotoxic/immunosuppressive
agent
• Immunosuppressive,
corticosteroid, or ACE Inhibitor
• Corticosteroid, topical retinoid,
biologic disease-modifying
antirheumatic drugs (DMARD),
non-biologic DMARD, or a non-
steroidal anti-inflammatory drug
(NSAID)
• Corticosteroid or analgesic
• Topical or oral corticosteroid,
antihistamine, or NSAID
• Analgesic, anti-infective agent,
and agents to reduce
inflammation, such as NSAIDs and
steroids
• Oral corticosteroid or an
immunosuppressive.
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 62
Drug / Class Name
Step Therapy (ST) Parameters
Frequency / Quantity / Duration
(F/Q/D) Parameters
Additional / Alternate
Parameter(s)
Anabolic Steroids – Injectable
• testosterone cypionate (Depo-
Testosterone®)
• testosterone enanthate
(Xyosted®)*
• Limitations for anabolic steroid
products is based on approved
FDA labeled daily dosing and
documented diagnosis not to
exceed a 90-day supply (30-day
supply for oxandrolone):
• Xyosted® is limited to no more
than 3 boxes for 90 days (1 box
per 30 days)
• Initial duration limit of 3 months
(for all products except
oxandrolone), requiring
documented follow-up monitoring
for response and/or adverse
effects before continuing
treatment
• Duration limit of 6 months for
delayed puberty
• Duration limit of 1 month for all
uses of oxandrolone products
*for additional parameters, see
Hormone Replacement Therapy for
Treatment of Gender Dysphoria
section below.
Anabolic Steroids – Oral
• testosterone undecanoate
(Jatenzo®, Tlando®)
• methyltestosterone (Methitest®)
• oxandrolone
Anti-Diarrheal Agents
• alosetron (Lotronex®)
• crofelemer (Mytesi®)
• eluxadoline (Viberzi®)
• telotristat (Xermelo®)
• Irritable Bowel Syndrome
w/Diarrhea
− Trial of eluxadoline and
rifaximin prior to alosetron.
• Symptomatic relief of non-
infectious diarrhea in patients
with HIV/AIDS on anti-retroviral
therapy
− Trial with an alternative anti-
diarrheal agent.
• Carcinoid Syndrome
− Trial with and concurrent use
with a somatostatin analog
• Confirmation of FDA-approved or
compendia-supported indication.
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 63
Drug / Class Name
Step Therapy (ST) Parameters
Frequency / Quantity / Duration
(F/Q/D) Parameters
Additional / Alternate
Parameter(s)
Anti-Retroviral (ARV) Interventions
QUANTITY LIMITS:
• Limit ARV active ingredient
duplication
• Limit ARV utilization to a
maximum of five products
concurrently - excluding boosting
with ritonavir (dose limit 600 mg
or less) or cobicistat
• Limit Protease Inhibitor utilization
to a maximum of two products
concurrently
• Limit Integrase inhibitor utilization
to a maximum of one product
concurrently
• Limit non-nucleoside reverse
transcriptase inhibitor utilization
to a maximum of 1 product
concurrently
• Limit ARV booster utilization to 1
product concurrently
• Limit co-formulated and co-
packaged complete ARV regimens
listed in Appendix A to a maximum
of 1 product concurrently with no
additional ARVs.
• Require confirmation of FDA-
approved or compendia-
supported use
• Point-of-service edit for
antiretroviral / antiretroviral
combinations to be avoided:
https://newyork.fhsc.com/downlo
ads/providers/NYRx_PDP_referen
ce_Antiretroviral_Antiretroviral_D
rug2Drug_Interactions.pdf
belimumab (Benlysta®)
• Trial of a disease-modifying anti-
rheumatic drug (DMARD) prior to
treatment with an
immunomodulator
• Confirm diagnosis of FDA-
approved or compendia-
supported indication
biotin
• Confirm diagnosis of FDA-
approved or compendia-
supported indication
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 64
Drug / Class Name
Step Therapy (ST) Parameters
Frequency / Quantity / Duration
(F/Q/D) Parameters
Additional / Alternate
Parameter(s)
Benzodiazepine agents – oral
• alprazolam (Xanax®, Xanax® XR)
• chlordiazepoxide
• chlordiazepoxide/amitriptyline
• clonazepam (Klonopin®)
• clorazepate
• diazepam (Valium®)
• lorazepam (Ativan®, Lorazepam
Intensol®, Loreev XR™)
• oxazepam
Generalized Anxiety Disorder (GAD) or
Social Anxiety Disorder (SAD)
• Require trial with a Selective-
Serotonin Reuptake Inhibitor
(SSRI) or a Serotonin-
Norepinephrine Reuptake
Inhibitor (SNRI) prior to initial
benzodiazepine prescription
• Panic Disorder requires concurrent
therapy with an antidepressant
(SSRI, SNRI, or Tricyclic
antidepressant [TCA]).
Skeletal muscle spasms
• Require trial with a skeletal muscle
relaxant prior to a benzodiazepine
DURATION LIMIT:
• For Insomnia: 30 consecutive days
• For Panic Disorder: 30 consecutive
days
• Require confirmation of FDA-
approved or compendia-
supported use
• PA required for initiation of
benzodiazepine therapy in
patients currently on opioid or
oral buprenorphine therapy
• PA required for any additional oral
benzodiazepine prescription in
patients currently on
benzodiazepine therapy
• PA required when greater than a
14-day supply of a benzodiazepine
is prescribed for someone on a
CNS stimulant
Constipation Agents
• linaclotide (Linzess®)
• lubiprostone (Amitiza®)
• methylnaltrexone (Relistor®)
• naldemedine (Symproic®)
• naloxegol (Movantik®)
• plecanatide (Trulance®)
• prucalopride (Motegrity™)
• tenapanor (Ibsrela®)
Opioid Induced Constipation (OIC) and
Chronic Idiopathic Constipation (CIC)
Trial with an osmotic laxative, a
stimulant laxative, and a stool
softener prior to use.
Irritable Bowel Syndrome w/
Constipation (IBS-C)
Trial with a bulking agent and an
osmotic laxative within 89 days of
use.
QUANTITY LIMIT:
• linaclotide, naldemedine,
naloxegol, plecanatide: 1
tablet/day
• lubiprostone: 2 capsules/day
• methylnaltrexone: 1 vial or
syringe/day, 4 kits/28 days
• prucalopride: 2 mg/day max; 1
tablet per day
• tenapanor 2 tablets/day
• Confirmation of FDA-approved or
compendia-supported indication.
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 65
Drug / Class Name
Step Therapy (ST) Parameters
Frequency / Quantity / Duration
(F/Q/D) Parameters
Additional / Alternate
Parameter(s)
Hormone Replacement Therapy for
Treatment of Gender Dysphoria
• conjugated estrogens
• estradiol
• testosterone cypionate
• testosterone enanthate
(Xyosted™)
• testosterone gel 1.62%
(AndroGel®)*
• testosterone patch (Androderm)*
• Confirm diagnosis of FDA-
approved or compendia-
supported indication
• For diagnosis of gender dysphoria
please refer to October 2023
edition of the Medicaid Update:
https://www.health.ny.gov/health
_care/medicaid/program/update/2
023/no15_2023-10.htm#hormones
*Subject to Anabolic Steroids – Topical
PDL class criteria
dextromethorphan / quinidine
(Nuedexta®)
QUANTITY LIMIT:
• 2 capsules per day; 60 units per 30
days
DURATION LIMIT:
• 90 days of therapy
For patients ≥ 18 years of age:
• Confirm diagnosis of FDA-
approved or compendia-
supported indication
Diabetic Test Strips
QUANTITY LIMIT:
• Type I DM – max 300 test strips
per 30-day supply
• Type II DM – max 100 test strips
per 30-day supply
• Preferred diabetic supply program
https://newyork.fhsc.com/provide
rs/diabeticsupplies.asp
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 66
Drug / Class Name
Step Therapy (ST) Parameters
Frequency / Quantity / Duration
(F/Q/D) Parameters
Additional / Alternate
Parameter(s)
dronabinol (Marinol®)
Step therapy for beneficiaries with
HIV/AIDS, or cancer, AND eating
disorder:
• Trial with megestrol acetate
suspension prior to dronabinol
Step therapy for beneficiaries with
diagnosis of cancer and
nausea/vomiting:
• Trial with a NYS Medicaid-
preferred 5-HT3 receptor
antagonist prior to dronabinol
• Confirm diagnosis of FDA-
approved or compendia-
supported indication
risdiplam (Evrysdi®)
• Confirm diagnosis of FDA-
approved indication
• Confirm absence of advanced
disease
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 67
Drug / Class Name
Step Therapy (ST) Parameters
Frequency / Quantity / Duration
(F/Q/D) Parameters
Additional / Alternate
Parameter(s)
Fentanyl Transmucosal Agents
• fentanyl (lozenge)
• fentanyl (Fentora®) (buccal tablet)
QUANTITY LIMIT:
fentanyl lozenge, Fentora®:
• 4 units per day, 120 units per 30
days
DURATION LIMIT:
• 90 days
• Exemption for diagnosis of cancer,
sickle cell disease, or hospice care
• Confirm diagnosis
• Limited to a total of 4 opioid
prescriptions every 30 days;
• For opioid-naïve patients: limited
to a 7 days’ supply for all initial
opioid prescriptions,
• PA required for use if > 90 MME
(MME = morphine milligram
equivalents) of opioid per day for
management of non-acute pain
(pain lasting > 7 days).
• PA required for initiation of opioid
therapy for patients on
established opioid dependence
therapy
• PA is required for initiation of
opioid therapy in patients
currently on benzodiazepine
therapy
• Exemption for diagnosis of cancer,
sickle cell, or hospice care
HIV PrEP (Pre-Exposure Prophylaxis
Agents):
• cabotegravir (Apretude)
• emtricitabine/tenofovir disoproxil
fumarate (Truvada®)
• emtricitabine/tenofovir
alafenamide (Descovy®)
• Confirmation of negative HIV test
every 3 months
ivermectin (oral)
• Confirm diagnosis of FDA-
approved or compendia-
supported indication
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 68
Drug / Class Name
Step Therapy (ST) Parameters
Frequency / Quantity / Duration
(F/Q/D) Parameters
Additional / Alternate
Parameter(s)
Lidocaine patches
lidocaine (Lidoderm®, ZTLido™)
• Prescribers, or their authorized
agents, are required to respond to
a series of questions that identify
the prescriber, the patient, and
the reason for prescribing this
drug.
• Prescriptions can be written for a
30-day supply with up to 2 refills
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 69
Drug / Class Name
Step Therapy (ST) Parameters
Frequency / Quantity / Duration
(F/Q/D) Parameters
Additional / Alternate
Parameter(s)
methadone
• Requires a trial of a long-acting
opioid prior to initiation for the
management of chronic non-
cancer pain
QUANTITY LIMIT:
• 12 units per day, 360 units per 30
days
• Exemption for diagnosis of cancer,
hospice care, or sickle cell disease
• Confirm diagnosis of chronic non-
cancer pain
• Limited to a total of 4 opioid
prescriptions every 30 days;
• PA required for initiation of
methadone for patients on
established opioid dependence
therapy
• PA required for methadone
prescriptions for patients currently
on long-acting opioid therapy.
• PA required for initiation of long-
acting opioid therapy in opioid-
naïve patients.
• PA required for use if > 90 MME
(MME = morphine milligram
equivalents) of opioid per day for
management of non-acute pain
(pain lasting > 7 days). PA required
for initiation of methadone
therapy in patients currently on
benzodiazepine therapy
• Exemption for diagnosis of cancer,
sickle cell, or hospice care
metoclopramide nasal spray (Gimoti™)
• Metoclopramide nasal spray
confirm diagnosis of diabetes
olanzapine / fluoxetine (Symbyax®)
• When prescribing for the
treatment of major depressive
disorder (MDD) in the absence of
other psychiatric comorbidities,
trial with at least one different
antidepressant agent is required
• PA is required for the initial
prescription for beneficiaries
younger than 10 years
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 70
Drug / Class Name
Step Therapy (ST) Parameters
Frequency / Quantity / Duration
(F/Q/D) Parameters
Additional / Alternate
Parameter(s)
Ovulation Enhancing Drugs
• bromocriptine
• clomiphene
• letrozole
• tamoxifen
• Confirm diagnosis of FDA-
approved or compendia-
supported indication and
Medicaid covered indication
• Refer to
https://www.health.ny.gov/health
_care/medicaid/program/update/
2019/2019-06.htm#ovulation
Oxazolidinone Antibiotics
• linezolid (Zyvox®)
• tedizolid (Sivextro®)
• Please be prepared to respond to
a series of questions that identify
the prescriber, the patient, and
the reason for prescribing this
drug.
• Please be prepared to fax clinical
documentation upon request.
Pubertal Suppressants
• leuprolide acetate (Lupron®,
Lupron Depot-PED®, Eligard®,
Fensolvi®, Lupron Depot®)
• nafarelin acetate (Synarel®)
• triptorelin (Triptodur®)
• Confirm diagnosis of FDA-
approved or compendia-
supported indication
• Refer to
https://www.health.ny.gov/health
_care/medicaid/program/update/
2017/2017-01.htm#transgender
for Transgender Related Care and
Services Update
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 71
Drug / Class Name
Step Therapy (ST) Parameters
Frequency / Quantity / Duration
(F/Q/D) Parameters
Additional / Alternate
Parameter(s)
esketamine (Spravato®)
• Treatment Resistant Depression:
trial of at least two oral
antidepressants
• Confirm diagnosis of FDA approved
indication for patients ≥18 years of
age
• Confirm concurrent use of an FDA
approved antidepressant
• Before initiating esketamine nasal
spray (Spravato), prescribers must
attest that they have obtained a
baseline score using a validated
clinical assessment tool for
depression (e.g., HAMD17, QIDS-
C16C, MADRS).
• After the initiation of esketamine
nasal spray (Spravato) therapy,
every six months prescribers must
attest that esketamine nasal spray
(Spravato) has resulted in an
improvement of depressive
symptoms (from baseline) using
the same baseline clinical
assessment tool for depression
(e.g., HAMD17, QIDS-C16C,
MADRS).The esketamine
worksheet can be accessed at:
https://newyork.fhsc.com/downlo
ads/providers/NYRx_PDP_PA_Wor
ksheet_Prescribers_Spravato.docx
tasimelteon (Hetlioz®, Hetlioz® LQ)
QUANTITY LIMIT:
• One unit per day; 30 units per 30
days
• Confirm diagnosis of FDA-approved
or compendia-supported indication
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 72
Drug / Class Name
Step Therapy (ST) Parameters
Frequency / Quantity / Duration
(F/Q/D) Parameters
Additional / Alternate
Parameter(s)
Parathyroid Hormone Analogs
• teriparatide (Forteo®)
• abaloparatide (Tymlos®)
• Requires a trial with a preferred
oral bisphosphonate
QUANTITY LIMIT:
• One unit per 30-day period
LIFETIME QUANTITY LIMIT:
• 25 months’ cumulative use of a
PTH analog
Topical Compounded Prescriptions
• Confirm diagnosis of FDA-
approved or compendia-
supported indication
• For non-opioid pain management
alternatives please visit:
https://health.ny.gov/health_care
/medicaid/program/opioid_manag
ement/docs/non_opioid_alternati
ves_to_pain_management.pdf
Zoryve® foam
Confirm diagnosis of FDA-approved
or compendia-supported indication
Minimum age: 9 years
For more information on DUR Program, please refer to https://www.health.ny.gov/health_care/medicaid/program/dur/index.htm.
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 73
Medication Assisted Treatment (MAT) Formulary
Effective 05/05/2022
Medication Assisted Treatment (MAT) Formulary
**Prior authorization will not be required for medications used for the treatment of substance use disorder when prescribed according to generally accepted
national professional guidelines for the treatment of a substance use disorder. **
Drugs
Coverage Parameters
Opioid Antagonists
Kloxxado™
naloxone (syringe, vial, nasal
spray)
naloxone (nasal spray) OTC
naltrexone
Narcan® (nasal spray)
Narcan® OTC
Opvee®
Rextovy®
RiVive™
Zimhi™
N/A
Opioid Dependence Agents – Injectable
Brixadi™
Vivitrol®
Sublocade™
N/A
Opioid Dependence Agents – Oral/Transmucosal
F/Q/D
buprenorphine (tablet)
buprenorphine/naloxone (tablet)
Suboxone® (film)
buprenorphine/naloxone (film)
Zubsolv®
QUANTITY LIMIT:
• buprenorphine sublingual (SL): Eight tablets dispensed as a 2-day supply; not to exceed 32 mg per day
• buprenorphine / naloxone tablet and film (Suboxone® 2mg/0.5mg, Zubsolv® 1.4mg/0.36mg, 0.7mg/0.18mg
strength; Up to 12 sublingual tablets or films per day.
• buprenorphine/naloxone tablet and film (Suboxone® up to 4mg/1mg and 8mg/2mg strength, Zubsolv®
2.9mg/0.71mg and 5.7mg/1/4mg strength; Four sublingual tablets or films per day; maximum of 120 tablets or films
dispensed as a 30-day supply, not to exceed 32 mg-8 mg of Suboxone®, or its equivalent per day
• buprenorphine/naloxone tablet: Suboxone® 12mg/3mg, Zubsolv® 8.6 mg/2.1 mg and Zubsolv® 11.4 mg/2.9 mg
strength: Maximum of 60 tablets dispensed as a 30-day supply
RELATED CLINICAL CRITERIA (CC)
• PA required for initiation of opioid therapy for patients on established opioid dependence therapy
• PA required for initiation of a CNS stimulant for patients established on opioid dependence therapy **
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 74
NYS Medicaid NYRx Brand Less Than Generic (BLTG) Program
On April 26, 2010, NYRx, the Medicaid Pharmacy Program, implemented a new cost-containment initiative, which promotes the use of certain multi-source
brand name drugs when the cost of the brand name drug is less expensive than the generic equivalent.
In conformance with State Education Law, which intends that patients receive the lower cost alternative, brand name drugs included in this program:
• Do not require “Dispense as Written” (DAW) or “Brand Medically Necessary” on the prescription
• Have a generic copayment
• Are paid at the Brand Name Drug reimbursement rate or usual and customary price, whichever is lower (SMAC/FUL are not applied)
• Do not require a new prescription if the drug is removed from this program
Effective August 1, 2024:
• Myrbetriq® and Victoza® will be added to the program
• Dexilant®, Lialda®, Renvela® tablet and powder pack will be removed from the program
List of Brand Name Drugs included in this program**
Advair Diskus®
Farxiga®
Retin-A® cream
Advair HFA®
Glumetza®
Risperdal Consta®
Alphagan P® 0.15%
Istalol®
Ritalin LA®
Alphagan P® 0.1%
Kitabis® Pak
Spiriva® Handihaler®
Apriso®
Kombiglyze® XR
Symbicort®
Azopt™
Myrbetriq®
Tegretol® suspension
Bethkis®
Nascobal®
Tegretol® XR
Carbaglu®
Nexavar®
Trileptal® suspension
CellCept® suspension
NuvaRing®
Vascepa®
Combigan®
Onglyza®
Ventolin® HFA
Copaxone® 20 mg SQ
Oseni®
Victoza®
Daytrana®
Pentasa®
Votrient®
Depakote® Sprinkle
Pradaxa®
Vyvanse® capsules
Dymista®
Protonix® suspension
Xigduo® XR
EpiPen
Pylera®
Xopenex HFA®
EpiPen, Jr
Restasis®
Zegerid® Rx
**List is subject to change
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 75
Please keep in mind that drugs in this program may be subject to prior authorization requirements of other pharmacy programs, promoting the use of the
most cost-effective product.
Important Billing Information
• Pursuant to this program, prescription claims submitted to the Medicaid program do not require the submission of Dispense as Written/Product Selection
Code of ‘1’; Pharmacies should submit DAW code 9 (Substitution Allowed by Prescriber but Plan Requests Brand). Pharmacies will receive an NCPDP reject
response of “22” which means missing/invalid DAW code if other DAW codes are submitted. The only exception to this is DAW code 1 and “Brand Medically
Necessary” on the prescription.
• For more information on the Brand Less Than Generic (BLTG) Program, please refer to https://newyork.fhsc.com/providers/bltgp_about.asp
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 76
NYS Medicaid NYRx Mandatory Generic Drug Program
State law excludes Medicaid coverage of brand name drugs that have a Federal Food and Drug Administration (FDA) approved A-rated generic equivalent unless
a prior authorization is obtained.
Coverage parameters under the Preferred Drug Program (PDP), Clinical Drug Review Program (CDRP), and/or the Brand Less Than Generic (BLTG) Program are
applicable for certain products subject to the Mandatory Generic Drug Program (MGDP), including exemptions (as listed below).
Prior Authorization Process
• Prescribers, or an agent of the prescriber, must call the prior authorization line at 1-877-309-9493 and respond to a series of questions that identify the
prescriber, the patient, and the reason for prescribing this drug. The Mandatory Generic Program Prescriber Worksheet and Instructions, located at
https://newyork.fhsc.com/providers/MGDP_forms.asp, provide step-by-step assistance in completing the prior authorization process.
• The prescriber must write “DAW and Brand Medically Necessary” on the face of the prescription.
• The call line 1-877-309-9493 is in operation 24 hours a day, seven days a week.
Exempt Drugs
• Based on specific characteristics of the drug and/or disease state generally treated, the following brand name drugs are exempt from the program and do
NOT require PA:
Exempt Drugs
Clozaril®
Neoral®
Dilantin®
Sandimmune®
Gengraf®
Tegretol®
Lanoxin®
Zarontin®
Levothyroxine Sodium (Unithroid®, Synthroid®, Levoxyl®)
For more information on the Mandatory Generic Program, please refer to https://newyork.fhsc.com/providers/MGDP_about.asp.
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 77
NYS Medicaid NYRx Dose Optimization Program
On November 14, 2013, the Medicaid NYRx program instituted a Dose Optimization initiative. Dose optimization can reduce prescription costs by reducing the
number of pills a patient needs to take each day. The Department has identified drugs to be included in this program, the majority of which have FDA approval for
once-a-day dosing, have multiple strengths available in correlating increments at similar costs and are currently being utilized above the recommended dosing
frequency. Prior authorization will be required to obtain the following medication beyond the following limits:
Dose Optimization Chart
Brand Name
Dose Optimization Limitations
CARDIOVASCULAR
Angiotensin Receptor Blockers (ARBs)
Benicar® 20 mg
1 daily
Tablet
Micardis® 20 mg, 40 mg
1 daily
Tablet
Diovan® 40 mg, 80 mg, 160 mg
1 daily
Tablet
Antiarrhythmics
Amiodarone 100 mg
1 daily
Tablet
In case of dose titration for these medications, the department will
allow for multiday dosing (up to 2 doses daily) for loading dose for
30 days
ARBs Combinations
Exforge® 5–160mg
1 daily
Tablet
ARBs/Diuretics
Benicar® HCT 20–12.5 mg
1 daily
Tablet
Diovan® HCT 80–12.5 mg, 160–12.5 mg
1 daily
Tablet
Edarbyclor® 40–12.5 mg
1 daily
Tablet
Micardis® HCT 40–12.5 mg, 80–12.5 mg
1 daily
Tablet
Beta Blockers
Bystolic® 2.5 mg, 5 mg, 10 mg
1 daily
Tablet
Coreg® CR 20 mg, 40 mg
1 daily
Tablet
nadolol 40 mg
1 daily
Tablet
Toprol® XL 25 mg, 50 mg, 100 mg
1 daily
Tablet
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 78
Brand Name
Dose Optimization Limitations
CENTRAL NERVOUS SYSTEM
Anticonvulsants
Aptiom® 200 mg, 400 mg
1 daily
Tablet
Fycompa® 4 mg, 6 mg
1 daily
Tablet
topiramate ER 100 mg
1 daily
Capsule
Lamictal XR® 50 mg
1 daily
Tablet
In case of dose titration for these medications, the department will
allow for multiday dosing (up to 2 doses daily) for titration
purposes for 90 days
Oxtellar XR® 300 mg
1 daily
Tablet
In case of dose titration for these medications, the department will
allow for multiday dosing (up to 2 doses daily) for titration
purposes for 90 days
Lyrica® 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200
mg
3 daily
Tablet
Electronic bypass for diagnosis of seizure disorder identified in
medical claims data. In case of dose titration for these medications,
the department will allow for multiday dosing (up to 2 doses daily)
for titration purposes for 3 months
Lyrica® 225 mg and 300 mg
2 daily
Tablet
Trokendi XR® 100 mg
1 daily
Tablet
Antiparkinson Agents
Azilect® 0.5 mg
1 daily
Tablet
Antipsychotics – Second Generation
Abilify® 2 mg
4 daily
Tablet
Abilify® 5 mg, 10 mg, 15 mg
1 daily
Tablet
In case of dose titration for these medications, the Department will
allow for multiday dosing (up to 2 doses/daily) for titration
purposes for three months
aripiprazole 5 mg, 10 mg, 15 mg
1 daily
Tablet
Invega® 1.5 mg, 3 mg
1 daily
Tablet
Latuda® 20 mg, 40 mg, 60 mg
1 daily
Tablet
olanzapine 5 mg, 10 mg
1 daily
Tablet
olanzapine ODT 5 mg, 10 mg
1 daily
Tablet
paliperidone er 1.5 mg, 3 mg
1 daily
Tablet
quetiapine fumarate er 200 mg
1 daily
Tablet
Rexulti® 0.25 mg, 0.5 mg, 1 mg, 2 mg
1 daily
Tablet
Seroquel® XR 150 mg, 200 mg
1 daily
Tablet
Symbyax® 3–25 mg, 6–25 mg, 12–25 mg
1 daily
Capsule
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 79
Brand Name
Dose Optimization Limitations
CENTRAL NERVOUS SYSTEM
Vraylar® 1.5 mg, 3 mg
1 daily
Capsule
Zyprexa® Zydis 5 mg, 10 mg
1 daily
Tablet
CNS Stimulants
Adderall® XR 5 mg, 10 mg, 15 mg
1 daily
Capsule
amphetamine salt combo ER 5 mg, 10 mg, 15 mg
1 daily
Capsule
Concerta® ER 18 mg, 27 mg
1 daily
Tablet
dexmethylphenidate ER 10 mg, 20 mg (Focalin XR
generic)
1 daily
Capsule
Focalin® XR 5 mg, 10 mg, 15 mg, 20 mg
1 daily
Capsule
methylphenidate CD 10 mg, 20 mg
1 daily
Capsule
methylphenidate er 18 mg (Concerta® generic)
1 daily
Tablet
methylphenidate la 20 mg (Ritalin® LA generic)
1 daily
Capsule
modafinil 100 mg
1 daily
Tablet
Provigil® 100 mg
1 daily
Tablet
QuilliChew® ER 20 mg
1 daily
Tablet
Ritalin® LA 10 mg, 20 mg
1 daily
Capsule
Vyvanse® 10 mg, 20 mg, 30 mg, 40 mg
1 daily
Capsule
Other Agents for Attention Deficit Hyperactivity Disorder (ADHD)
guanfacine ER 1 mg, 2 mg
1 daily
Tablet
atomoxetine 40 mg
1 daily
Capsule
Intuniv® 1 mg, 2 mg
1 daily
Tablet
Strattera® 40 mg
1 daily
Capsule
Sedative Hypnotics
Lunesta® 1 mg
1 daily
Tablet
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Effexor® XR 37.5 mg, 75 mg, 150 mg
1 daily
Capsule
In the case of dose titration for these medications, the Department
will allow for multiday dosing (up to 2 doses/daily) for titration
purposes for three months.
desvenlafaxine succinate ER (Pristiq® ER 50 mg)
1 daily
Tablet
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 80
Brand Name
Dose Optimization Limitations
CENTRAL NERVOUS SYSTEM
Selective Serotonin Reuptake Inhibitors (SSRIs)
Lexapro® 5 mg, 10 mg
1 daily
Tablet
In the case of dose titration for these once daily medications, the
Department will allow for multiday dosing (up to 2 doses/daily) for
titration purposes for three months.
Trintellix® 5 mg, 10 mg
1 daily
Tablet
Viibryd® 10 mg, 20 mg
1 daily
Tablet
Miscellaneous Antidepressants
bupropion xl 150 mg
1 daily
Tablet
In case of dose titration for these medications, the Department will
allow for multiday dosing (up to 2 doses/daily) for titration
purposes for three months
mirtazapine 7.5 mg
1 daily
Tablet
Brand Name
Dose Optimization Limitations
ENDOCRINE AND METABOLIC
Biguanides
metformin ER 500 mg (Glumetza ER, Fortamet ER
generic)
1 daily
Tablet
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
Januvia® 25 mg, 50 mg
1 daily
Tablet
Onglyza® 2.5 mg
1 daily
Tablet
Thiazolidinediones (TZDs)
Actos® 15 mg
1 daily
Tablet
Brand Name
Dose Optimization Limitations
GASTROINTESTINAL
Proton Pump Inhibitors
Dexilant® 30 mg
1 daily
Capsule
Nexium® 5 mg, 10 mg, 20 mg
1 daily
Packet
Nexium® 20 mg
1 daily
Capsule
Revised: August 01, 2024
Standard PA fax form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf 81
Brand Name
Dose Optimization Limitations
GASTROINTESTINAL
Prevacid® DR 15 mg
1 daily
Capsule
Brand Name
Dose Optimization Limitations
HEMATOLOGICAL
Anticoagulants - Oral
Xarelto® 10 mg
1 daily
Tablet
Brand Name
Dose Optimization Limitations
RENAL AND GENITOURINARY
Urinary Tract Antispasmodics
Detrol® LA 2 mg
1 daily
Capsule
Myrbetriq® 25 mg
1 daily
Tablet
oxybutynin chloride ER 5 mg
1 daily
Tablet
Toviaz® ER 4 mg
1 daily
Tablet
VESIcare® 5 mg
1 daily
Tablet
PA requirements are not dependent on the date a prescription is written. New prescriptions and refills on existing prescriptions require PA even if the
prescription was written before the date the drug was determined to require PA.
To obtain a prior authorization (PA), please call the prior authorization Clinical Call Center at 1-877-309-9493. The Clinical Call Center is available 24 hours per
day, 7 days per week with pharmacy technicians and pharmacists who will work with you, or your agent, to quickly obtain PA.
Medicaid enrolled prescribers with an active e-PACES account can initiate PA requests through the web-based application PAXpress®. The website for PAXpress
is https://paxpress.nypa.hidinc.com.
When, in the judgment of the prescriber or the pharmacist, an emergency condition exists, the prescriber or pharmacist can call the Clinical Call center and
obtain authorization for a 72-hour emergency supply of the drug prescribed to allow time for the prior authorization to be obtained.
