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Prescription Drug Polices

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Prescription Drug Polices - Top Content

The following is a list of our prescription drug policies. If you cannot find a policy for a specific medication, please select the link titled 'Clinical Review Prior Authorization' from the list below.


*Pharmacy benefit drugs - Univera Healthcare continues to manage the pharmacy benefit for Medicaid Managed Care and Child Health Plus members. Use the Univera Pharmacy Management Drug Policies below.

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We invite practitioners to review & comment on our policies.

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Showing 26– 50 of 56 Results
Title Last Updated
Interleukin Antagonists for Asthma and Other Conditions: Nucala (mepolizumab), Cinqair (reslizumab), Fasenra (benralizumab), & Dupixent (dupilumab) Open a PDF 10/18/2019
IVIG/SCIG Open a PDF 11/25/2019
Medicaid Managed Care Step Therapy Policy Open a PDF 11/11/2019
Medicare D 2020 Prior Authorization Policy Open a PDF 01/20/2020
Medicare D 2020 Step Therapy Policy Open a PDF 01/30/2020
Medicare D Formulary-Level Cumulative Opioid and Opioid / Buprenorphine POS Edits Open a PDF 11/25/2019
Non-Formulary Medication Exception Review Policy for All Lines of Business Open a PDF 9/12/2019
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Open a PDF 1/1/2020
Off Label Use Open a PDF 6/6/2019
Oncology Clinical Review Prior Authorization Medical Drug (Adcetria, Aliqopa, Arzerra, Asparlas, Bavencio, Beleodaq, Belrapzo, Bendeka, Besponsa, Blincyto, Cyramza, Darzalex, Elzonris, Empliciti, Enhertu, Erwinaze, Folotyn, Gazyva, Halaven, Herceptin Hylecta, Imfinzi, Istodax and Romidepsin, Jevtana, Kadcyla, Keytruda, Kymriah, Kyprolis, Lartruvo, Libtayo, Lumoxiti, Marqibo, Mozobil, Mylotarg, Oncaspar, Onivyde, Opdivo, Padcev, Perjeta, Polivy, Portrazza, Poteligeo, Provenge, Synribo, Tecentriq, Torisel, Treanda, Vyxeos, Xgeva, Yervoy, Yescarta, Yondelis, Zaltrap) Open a PDF 2/3/2020
Oncology Clinical Review Prior Authorization Rx Open a PDF 1/22/2020
Opioid Management Health & Safety Program Open a PDF 10/25/2019
Osteoporosis - Evenity® (romosozumab-aqqg), Forteo® (teriparatide), Prolia® (denosumab), Tymlos® (abaloparatide), Boniva injection® (Ibandronate) Open a PDF 11/21/2019
Patient Protection and Affordable Care Act - Preventive Items and Services Open a PDF 1/1/2020
PCSK9 Inhibitors Open a PDF 9/20/2019
PDE-5 Inhibitor Drugs-Medical Necessity Review (MMC & HARP) Open a PDF 12/15/2019
Pulmonary Arterial Hypertension (PAH) Open a PDF 11/6/2019
Quantity Limit Open a PDF 2/5/2020
Remicade (infliximab), Renflexis (infliximab-adba) Open a PDF 1/6/2020
Rituxan, Rituxan Hycela Open a PDF 2/6/2020
Sickle Cell Disease Management Policy Open a PDF 12/16/2019
Spinal Muscular Atrophy (SMA) - Spinraza (nusinersen) and Zolgensma (onasemnogene abeparovec-xioi) Open a PDF 09/27/2019
Stelara Open a PDF 1/1/2020
Step Therapy Policy for Commercial Open, Select Self-Funded Commercial Closed, Child Health Plus, Essential Plan, Small Employer Group and Direct Pay Metal Plans Open a PDF 2/4/2020
Summary of Inflectra Studies Open a PDF
Showing 26– 50 of 56 Results