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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 57 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 3/10/2020
Medicaid Managed Care Step Therapy Policy Open a PDF 3/15/2020
Medicare D 2020 Prior Authorization Policy Open a PDF 03/30/2020
Medicare D 2020 Step Therapy Policy Open a PDF 03/30/2020
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 4/3/2020
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Open a PDF 3/5/2020
Ocrevus for Medicaid, Child Health Plus and Essential Plan Open a PDF 2/3/2020
Off Label Use Open a PDF 6/6/2019
Oncology Clinical Review Prior Authorization Medical Drugs - (Adcetria, Aliqopa, Arzerra, Asparlas, Bavencio, Beleodaq, Besponsa, Blincyto, Cyramza, Darzalex, Elzonris, Empliciti, Enhertu, Erwinaze, Folotyn, Gazyva, Herceptin Hylecta, Imfinzi, Istodax & Romidepsin, Kadcyla, Keytruda, Kymriah, Kyprolis, Lartruvo, Libtayo, Lumoxiti, Marqibo, Mylotarg, Oncaspar, Onivyde, Opdivo, Padcev, Polivy, Portrazza, Poteligeo, Provenge, Synribo, Tecentriq, Torisel, Vyxeos, Xgeva, Yervoy, Yescarta, Yondelis, Zaltrap) Open a PDF 3/23/2020
Oncology Clinical Review Prior Authorization Rx Open a PDF 4/2/2020
Opioid Management Health & Safety Program Open a PDF 4/1/2020
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 2/19/2020
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
Safety Net – Oncology Clinical Review Prior Authorization Medical Drugs Open a PDF 2/3/2020
Sickle Cell Disease Management Policy Open a PDF 2/21/2020
Spinal Muscular Atrophy (SMA) – Spinraza (nusinersen) and Zolgensma (onasemnogene abeparovec-xioi) Open a PDF 2/26/2020
Stelara Open a PDF 2/27/2020
Showing 26– 50 of 57 Results