Prescription Drug Polices

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.

Showing 1– 25 of 58 Results

Title	Last Updated
Aduhelm (aducanumab-avwa) Policy Open a PDF	2/23/2022
Alpha-1 Antitrypsin Therapy (AAT) Open a PDF	9/1/2021
Anorexiants; Contrave (naltrexone/bupropion ER), Qsymia (phentermine/topiramate ER), Saxenda (liraglutide), Wegovy (semaglutide) and Xenical® (orlistat), Imcivree (setmelanotide) Open a PDF	1/3/2022
Antihemophilic Agents (For Managed Medicaid and HARP) Open a PDF	3/8/2022
Attention Deficit Hyperactivity Disorder (ADHD) Stimulants Policy Open a PDF	5/11/2022
Blood Modifiers Open a PDF	4/26/2022
Botulinum Toxin (Botox, Dysport, Myobloc, Xeomin) – For Medicaid Managed Care Essential Plan and Child Health Plus Open a PDF	12/2/2021
Chimeric Antigen Receptor T Cell (CAR-T) Therapy Open a PDF	4/26/2022
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	3/16/2022
Cimzia (Certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis and Rheumatoid Arthritis Open a PDF	4/4/2022
Clinical Review Prior Authorization (CRPA) Medical Drugs (Cablivi, Ceprotin, Hydroxyprogesterone, Krystexxa, Lemtrada, Leqvio, NPlate, Ocrevus, Saphnelo, Spravato, Trogarzo, Tysabri, Vabysmo, Zoladex, or any other Medical agent) Open a PDF	5/4/2022
Clinical Review Prior Authorization Rx (CRPA) Open a PDF	5/11/2022
Compounded Drug Products Open a PDF	2/10/2022
Coronavirus (COVID-19) Impacted Drug Therapies (azithromycin, chloroquine, hydroxychloroquine, ivermectin, Kaletra, lopinavir/ritonavir, Plaquenil, Stromectol, Zithromax) Open a PDF	2/10/2022
Duchenne Muscular Dystrophy (DMD): Amondys 45 (casimersen), Emflaza (deflazacort), Exondys 51 (eteplirsen), Viltepso (vilotarsen) and Vyondys 53 (golodirsen) Open a PDF	3/31/2022
Enbrel (etanercept) – for Ankylosing Spondylitis, Juvenile Idiopathic Arthritis, Plaque Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis Open a PDF	2/21/2022
Generic Advantage Program / MAC Penalty Open a PDF	5/11/2022
Growth Hormone Open a PDF	2/10/2022
Headache Disorders Open a PDF	3/9/2022
Hemlibra Open a PDF	5/6/2021
Hereditary Angioedema (HAE) Open a PDF	2/10/2022
Humira ® (adalimumab) – for Psoriasis, Rheumatoid Arthritis, Juvenile Idiopathic Arthritis, Psoriatic Arthritis, Ankylosing Spondylitis, Hidradenitis Suppurativa, Crohn’s Disease, Ulcerative Colitis and Panuveitis Open a PDF	3/30/2022
Immune Checkpoint Inhibitor (CPI) Clinical Review Prior Authorization (CRPA) (Bavencio, Imfinzi, Jemperli, Keytruda, Libtayo, Opdivo, Tecentriq, and Yervoy) Open a PDF	4/6/2022
Inborn Errors of Metabolic Diseases (IEM) Open a PDF	5/9/2022
Infertility Medications Open a PDF	11/19/2021

Showing 1– 25 of 58 Results