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 56 Results

Title	Last Updated
Acthar Gel® (Repository Corticotropin Injection) - for Infantile Spasms, Multiple Sclerosis Exacerbations Open a PDF	5/6/2021
Alpha-1 Antitrypsin Therapy (AAT) Open a PDF	5/6/2021
Anorexiants; Contrave (naltrexone/bupropion ER), QsymiaTM (phentermine/topiramate ER), Saxenda (liraglutide), Wegovy (semaglutide) and Xenical® (orlistat), Imcivree (setmelanotide) Open a PDF	6/24/2021
Antihemophilic Agents Open a PDF	5/10/2021
Attention Deficit Hyperactivity Disorder (ADHD) Stimulants Policy Open a PDF	7/19/2021
Blood Modifiers Open a PDF	7/15/2021
Botulinum Toxin (Medical Policy) Open a PDF	10/22/2020
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	12/4/2020
Cimzia Open a PDF	1/1/2021
Clinical Review Prior Authorization (CRPA) Medical Drugs Open a PDF	4/14/2021
Clinical Review Prior Authorization Rx (CRPA) Open a PDF	7/19/2021
Compounded Drug Products Open a PDF	2/11/2021
Coronavirus (COVID-19) Impacted Drug Therapies (azithromycin, chloroquine, hydroxychloroquine, Kaletra, lopinavir/ritonavir, Plaquenil, Zithromax) Open a PDF	2/11/2021
Duchenne Muscular Dystrophy (DMD): Amondys 45, (Exondys 51 (eteplirsen) and Vyondys 53 (golodirsen)) Open a PDF	6/16/2021
Enbrel Open a PDF	1/1/2021
Generic Advantage Program / MAC Penalty Open a PDF	6/8/2021
Growth Hormone Open a PDF	2/11/2021
Headache Disorders Open a PDF	6/30/2021
Hemlibra Open a PDF	3/2/2021
Hereditary Angioedema (HAE) Open a PDF	3/9/2021
Humira Open a PDF	10/05/2020
Immune Checkpoint Inhibitor Clinical Review Prior Authorization (CRPA) (Bavencio, Imfinzi, Jemperli, Keytruda, Libtayo, Opdivo, Tecentriq, Yervoy) Open a PDF	7/2/2021
Inborn Errors of Metabolic Diseases (IEM) Open a PDF	6/7/2021
Infertility Open a PDF	4/8/2021
Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs PDF Open a PDF	6/16/2021

Showing 1– 25 of 56 Results