Welcome to the Clinical Criteria Page

This page provides the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. The effective dates for using these documents for clinical reviews are communicated through the Provider notification process.

 

To determine if a code requires authorization, use the NY Prior Authorization lookup tool or WNY Precertification lookup tool

 

The New York Medicaid state-specific clinical criteria information is alphabetized below. Not all drugs requiring authorization have New York Medicaid State specific criteria. If a code requires authorization and the clinical criteria document is not found in the list below, please utilize the following link for additional criteria.Clinical Criteria

 

(Note: in the case of a clinical criteria document being listed on both sites, please utilize those listed directly above.)

 

If you have questions or feedback, please contact druglist@carelon.com.