Prescription Drug Policies

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.

Beginning April 1, 2023, all Medicaid members enrolled in Univera MyHealth and Univera MyHealth Plus will receive their prescription drugs through NYRx, the Medicaid Pharmacy Program.

Learn more about the transition of the pharmacy benefit from Univera MyHealth and Univera MyHealth Plus to NYRx, the Medicaid Pharmacy Program.

Access general information about NYRx, the Medicaid Pharmacy Program, along with additional information for Members and Providers.

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We invite practitioners to review & comment on our policies.

Showing 1– 25 of 58 Results
Title Last Updated
Adalimumab (Humira® [adalimumab], Amjevita™ [adalimumab-atto], Cyltezo® [adalimumab-adbm], Hadlima™ [adalimumab-bwwd], Hulio®/adalimumab-fkjp [adalimumab-fkjp], Hyrimoz®/adalimumab-adaz [adalimumab-adaz], Idacio® [adalimumab-aacf], Yuflyma® [adalimumab-aaty], Yusimry™ [adalimumab-aqvh] Open a PDF 9/1/2023
Alpha-1 Antitrypsin Therapy (AAT) Open a PDF 3/20/2023
Amyotrophic Lateral Sclerosis (ALS) Policy - (Exservan - riluzole oral film (Rx), Radicava and Radicava ORS - edaravone injection and kit (Rx/Medical), Relyvrio - sodium phenylbutyrate and taurursodiol (Rx), Tiglutik-riluzole oral suspension (Rx), & Qalsody-tofersen (Medical)) Open a PDF 5/30/2023
Anti-Amyloid Directed Therapies Policy (Aduhelm (aducanumab-avwa) & Leqembi (lecanemab-irmb)) Open a PDF 9/7/2023
Antihemophilic Agents (For Managed Medicaid and HARP) Open a PDF 07/17/2023
Attention Deficit Hyperactivity Disorder (ADHD) Stimulants - (Adhansia XR, Adzenys ER (amphetamine ER suspension), Adzenys XR ODT (amphetamine ER ODT), Azstarys, Cotempla XR ODT (methylphenidate ER ODT), Daytrana (methylphenidate patch), Desoxyn (methamphetamine), Dyanavel XR (amphetamine ER suspension), Dyanavel XR (methylphenidate patch), Jornay PM (methylphenidate ER capsules), Managed Medicaid members only: (Central Nervous System (CNS) stimulants used in combination with medication assisted treatment (MAT) therapy), Mydayis, Qelbree (viloxazine ER capsules), Quillichew ER (methylphenidate ER chewable tablets), Quillivant (methylphenidate ER suspension), Xelstrym) Open a PDF 4/1/2023
Blood Modifiers - (Cosela, Fulphila, Fylnetra, Granix, Neulasta, Neupogen, Nivestym, Nyvepria, Releuko, Rolvedon, Udenyca, Ziextenzo) Open a PDF 07/28/2023
Botulinum Toxin (Botox, Dysport, Myobloc, Xeomin) – For Medicaid Managed Care Essential Plan and Child Health Plus Open a PDF 08/24/2023
Chimeric Antigen Receptor T Cell (CAR-T) Therapy Open a PDF 11/15/2022
Chronic Hepatitis C (Pegasys, Peg-Intron, ribavirin, Sovaldi, Harvoni, ledipasvir/sofosbuvir, Zepatier, Epclusa, sofosbuvir/velpatasvir, Vosevi, Mavyret) for Commercial, NYSOH Individual Market, NYSOH Employer Group Market Products, and Managed Medicaid products (Vosevi only) Open a PDF 04/01/2023
Cimzia (Certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis and Rheumatoid Arthritis Open a PDF 9/1/2023
Clinical Review Prior Authorization (Medical Benefit) - (Briumvi (ublituximab-xiiy) (Medical), Cablivi (caplacizumab-yhdp) (Rx & Medical), Ceprotin (Protein C Concentrate, Human) (Medical), Eylea HD (aflibercept) (Medical), Fensolvi (leuprolide acetate), Hydroxyprogesterone Caproate Injection (Medical), Krystexxa - pegloticase (Medical), Lemtrada - alemtuzumab (Medical), Leqvio - inclisiran (Medical), Nplate - romiplostim (Medical), Ocrevus (ocrelizumab) (Medical), Rebyota - fecal microbiota,live-jslm (Medical), Saphnelo – anifrolumab-fnia (Medical), Spravato – esketamine nasal spray (Medical), Sunlenca (lenacapavir) (Rx & Medical), Supprelin LA (histrelin acetate) (Medical), Syfovre - pegcetacoplan injection (Medical), Triptodur (triptorelin), Trogarzo (ibalizumab-uiyk) (Medical), Trogarzo – ibalizumab-uiyk (Medical), Tysabri (natalizumab) (Medical), Vabysmo - faricimab-svoa (Medical), Zilretta – triamcinolone acetonide extended-release (Medical), Zoladex – goserelin implant (Medical), or any other medical agent) Open a PDF 9/12/2023
Clinical Review Prior Authorization Rx (CRPA) Open a PDF 09/20/2023
Compounded Drug Products Policy Open a PDF 08/11/2023
Coronavirus (COVID-19) Impacted Drug Therapies (Hydroxychloroquine, Lagevrio (molnupiravir), Paxlovid (nirmatrelvir/ritonavir), Stromectol (ivermectin)) Open a PDF 4/1/2023
Duchenne Muscular Dystrophy (DMD): Amondys 45 (casimersen), Emflaza (deflazacort), Exondys 51 (eteplirsen), Viltepso (vilotarsen) and Vyondys 53 (golodirsen) Open a PDF 9/22/2022
Enbrel (etanercept) – for Ankylosing Spondylitis, Juvenile Idiopathic Arthritis, Plaque Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis Open a PDF 08/24/2023
Generic Advantage Program / MAC Penalty Open a PDF 07/10/2023
Growth Hormone Policy Open a PDF 07/11/2023
Headache Disorder – (Aimovig (erenumab-aooe) (Rx), Ajovy (fremanezumab-vfrm) (Rx & Medical), D.H.E 45, dihydroergotamine 1 mg/mL ampule (Rx), Emgality 120 mg (galcanezumab-gnlm) (Rx), Emgality 300 mg (galcanezumab-gnlm) (Rx), Migranal, dihydroergotamine 4 mg/mL nasal spray, Trudhesa (Rx), Nurtec ODT (rimegepant) (Rx), Qulipta (atogepant) (Rx), Reyvow (lasmiditan) (Rx), Ubrelvy (ubrogepant) (Rx), Vyepti (eptinezumab-jjmr) (Medical), Zavzpret (zavegepant) (Rx) & Quantity Limit Criteria for Ubrelvy, Nurtec ODT, Reyvow, and Zavzpret) Open a PDF 08/24/2023
Hemgenix (etranacogene dezaparvovec-drlb) Open a PDF 2/14/2023
Hemlibra (emicizumab-kxwh) Open a PDF 12/15/2022
Hereditary Angioedema (HAE) For Berinert, Cinryze, Firazyr, Icatibant Haegarda, Kalbitor, Orladeyo, Ruconest, Sajazir, and Takhzyro Open a PDF 3/15/2023
Immune Checkpoint Inhibitor (CPI) Clinical Review Prior Authorization (CRPA) (Bavencio, Imfinzi, Imjudo, Jemperli, Keytruda, Libtayo, Opdivo, Tecentriq, and Yervoy) Open a PDF 3/20/2023
Inborn Errors of Metabolism & Rare Genetic Diseases - Amvuttra (vutrisiran), Brineura (cerliponase alfa), Carbaglu and generic carglumic acid, Cerdelga (eliglustat), Cerezyme (imiglucerase), Cholbam (cholic acid), Crysvita (burosumab-twza), Dojolvi (tripheptanoin oral liquid), Elaprase (idursulfase), Elelyso (taliglucerase alfa), Fabrazyme (agalisidase beta), Galafold (migalastat), Givlaari (givosiran) –, Javygtor and generic sapropterin, Kanuma (sebelipase alfa), Kuvan, Lamzede, Lumizyme (alglucosidase alfa), Mepsevii (vestronidase alfa-vjbk), Naglazyme (galsulfase), Nexviazyme (avalglucosidase alfa-ngpt), nitisinone capsule, Nityr (nitisinone) and Orfadin (nitisinone), Nulibry (fosdenopterin), Onpattro (patisiran), Oxlumo (lumasiran), Palynziq (pegvaliase-pqpz), Ravicti (glycerol phenylbutyrate), Strensiq (asfotase alfa), Sucraid (sacrosidase), Tegsedi (inotersen), Vimizim (elosulfase alfa)-Vimizim (elosulfase alfa), VPRIV (velaglucerase alfa), Vyndaqel (tafamidis meglumine), Vyndamax (tafamidis), Xenpozyme (olipudase alfa-rpcp), Xuriden (uridine triacetate), Zavesca / miglustat Open a PDF 8/16/2023
Showing 1– 25 of 58 Results

 

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