Archive
New York State Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance
| Drug or Drug Class Name | Policy/Guidance | Clinical Criteria Worksheet Fillable PDF* File |
|---|---|---|
| AbobotulinumtoxinA (Dysport®) | October 2022 November 2022 |
Dysport (PDF) |
| Betibeglogene autotemcel (Zynteglo ®) | January 2024 | Zynteglo (PDF) |
| Chimeric Antigen Receptor (CAR) T-cell Therapy | October 2021 | N/A** |
| Duchenne Muscular Dystrophy (DMD) | January 2022 | DMD (PDF) |
| Elivaldogene autotemecel (Skysona®) | December 2023 | Skysona (PDF) |
| Esketamine (Spravato®) Nasal Spray | August 2022 | Spravato (PDF) |
| Etranacogene dezaparvovec-drlb (Hemgenix®) | December 2023 | Hemgenix (PDF) |
| Goserlin implant (Zoladex ®) | March 2022 | Zoladex (PDF) |
| IncobotulinumtoxinA (Xeomin ®) | October 2022 November 2022 |
Xeomin (PDF) |
| Infliximab products | October 2022 March 2023 |
Infliximab (PDF) |
| Nusinersen (Spinraza®) | March 2023 | Spinraza (PDF) |
| OnabotulinumtoxinA (Botox®) | October 2022 November 2022 |
Botox (PDF) |
| Onasemenogene aberparvovec-xioi (Zolgensma ®) | November 2019 | Zolgensma (PDF) |
| RimabotulinumtoxinB (Myobloc ®) | October 2022 November 2022 |
Myobloc (PDF) |
| Vedolizumab (Entyvio®) | October 2022 March 2023 |
Entyvio (PDF) |
| Viscosupplementation with Hyaluronan or Derivative | April 2022 | Viscosupplementation (PDF) |
| Voretigine neparvovec-rzyl (Luxturna™) | Luxturna (PDF) | N/A** |
* PDF - Portable Document Format
** N/A - Not Applicable
| Drug or Drug Class Name | Policy/Guidance | Clinical Criteria Worksheet Fillable PDF* File |
|---|---|---|
| Aducanumab-avwa (Aduhelm ®) | October 2022 November 2022 |
Aduhelm (PDF) |
| Crizanlizumab-tmca (Adakveo®) | May 2020 | Adakveo (PDF) |
| Drug or Drug Class Name | Clinical Criteria Worksheet Fillable PDF* File |
|---|---|
| AbobotulinumtoxinA (Dysport®) | Dysport (PDF) |
| Betibeglogene autotemcel (Zynteglo ®) | Zynteglo (PDF) |
| Duchenne Muscular Dystrophy (DMD) | DMD (PDF) |
| Elivaldogene autotemecel (Skysona®) | Skysona (PDF) |
| Esketamine (Spravato®) Nasal Spray | Spravato (PDF) Spravato (PDF) |
| Etranacogene dezaparvovec-drlb (Hemgenix®) | Hemgenix (PDF) |
| Goserlin implant (Zoladex ®) | Zoladex (PDF) |
| IncobotulinumtoxinA (Xeomin ®) | Xeomin (PDF) |
| Infliximab products | Infliximab (PDF) |
| Nusinersen (Spinraza®) | Spinraza (PDF) |
| OnabotulinumtoxinA (Botox®) | Botox (PDF) |
| Onasemenogene aberparvovec-xioi (Zolgensma ®) | Zolgensma (PDF) |
| RimabotulinumtoxinB (Myobloc ®) | Myobloc (PDF) |
| Vedolizumab (Entyvio®) | Entyvio (PDF) |
| Viscosupplementation with Hyaluronan or Derivative | Viscosupplementation (PDF) |
