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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 1– 25 of 57 Results
Title Last Updated
Summary of Inflectra Studies Open a PDF
Medicare D 2020 Step Therapy Policy Open a PDF 03/30/2020
Medicare D 2020 Prior Authorization Policy Open a PDF 03/30/2020
Acthar Open a PDF 05/16/2019
Patient Protection and Affordable Care Act - Preventive Items and Services Open a PDF 1/1/2020
Hereditary Angioedema (HAE) Open a PDF 1/13/2020
Zulresso (brexanolone injection) for Postpartum Depression Open a PDF 1/13/2020
Attention Deficit Hyperactivity Disorder (ADHD) Stimulants Policy Open a PDF 1/2/2020
Hepatitis-C Medicaid Rx Open a PDF 1/23/2020
Hepatitis-C Commercial Rx Open a PDF 1/23/2020
Remicade (infliximab), Renflexis (infliximab-adba) Open a PDF 1/6/2020
Avastin (bevacizumab) & Mvasi (bevacizumab-awwb) Open a PDF 1/6/2020
Interleukin Antagonists for Asthma and Other Conditions: Nucala (mepolizumab), Cinqair (reslizumab), Fasenra (benralizumab), & Dupixent (dupilumab) Open a PDF 10/18/2019
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
Medicare D Formulary-Level Cumulative Opioid and Opioid / Buprenorphine POS Edits Open a PDF 11/25/2019
Infertility Open a PDF 11/6/2019
PDE-5 Inhibitor Drugs-Medical Necessity Review (MMC & HARP) Open a PDF 12/15/2019
Blood Modifiers Open a PDF 12/2/2019
Xolair Open a PDF 2/10/2020
Oncology Clinical Review Prior Authorization Rx Open a PDF 2/17/2020
Pulmonary Arterial Hypertension (PAH) Open a PDF 2/19/2020
Inborn Errors of Metabolic Diseases (IEM) Open a PDF 2/19/2020
Duchenne Muscular Dystrophy (DMD): (Exondys 51 (eteplirsen) and Vyondys 53 (golodirsen)) Open a PDF 2/20/2020
Sickle Cell Disease Management Policy Open a PDF 2/21/2020
Showing 1– 25 of 57 Results