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 |
|---|---|---|
| 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) |
