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 62 Results
Title Last Updated
Adalimumab (Humira® [adalimumab], Abrilada (adalimumab-afzb), 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 12/19/2023
Alpha-1 Antitrypsin Therapy (AAT) Open a PDF 3/20/2023
Amyotrophic Lateral Sclerosis (ALS) Policy - (Exservan (Rx), Qalsody (Medical), Radicava and Radicava ORS (Rx/Medical), Relyvrio (Rx), & Tiglutik (Rx)) Open a PDF 02/09/2024
Anti-Amyloid Directed Therapies Policy (Aduhelm (aducanumab-avwa) & Leqembi (lecanemab-irmb)) Open a PDF 9/7/2023
Antihemophilic Agents (for Medicaid Managed Care, HARP, & D-SNP) Open a PDF 1/24/2024
Attention Deficit Hyperactivity Disorder (ADHD) Policy - Azstarys, dextroamphetamine/amphetamine ER capsule (generic Mydayis), Dyanavel XR, Mydayis and Xelstrym, Adzenys XR ODT (amphetamine ER ODT), Adzenys ER (and generic amphetamine ER suspension), Cotempla XR ODT (methylphenidate ER ODT), Dyanavel XR (amphetamine ER suspension), Quillichew ER (methylphenidate ER chewable tablets), Quillivant (methylphenidate ER suspension), Desoxyn, and generic methamphetamine (Rx), Jornay PM - methylphenidate ER capsules, Qelbree – viloxazine ER capsules Open a PDF 01/25/2024
Blood Modifiers - Rx (Self Administration) & Medical Benefits (Health Professional Administered) (Cosela, Fulphila, Fylnetra, Granix, Neupogen, Nivestym, Nyvepria, Releuko, Rolvedon, Stimufend, Ziextenzo) Open a PDF 01/18/2024
Botulinum Toxin (Botox, Daxxify, Dysport, Myobloc, Xeomin) – for Medicaid Managed Care, Essential Plan, Child Health Plus, and Dual Eligible Special Needs Plan (D-SNP) Open a PDF 12/1/2023
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 12/06/2023
Cimzia (Certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis and Rheumatoid Arthritis Open a PDF 12/06/2023
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 01/09/2024
Clinical Review Prior Authorization Rx (CRPA) Open a PDF 01/25/2024
Compounded Drug Products Policy Open a PDF 01/29/2024
Coronavirus (COVID-19) Impacted Drug Therapies (Hydroxychloroquine, Lagevrio (molnupiravir), Paxlovid (nirmatrelvir/ritonavir), Stromectol (ivermectin)) Open a PDF 12/13/2023
Diabetic Incretin Mimetic Agents Policy Open a PDF 01/01/2024
Dual Special Needs Plan (D-SNP) 2024 Prior Authorization Policy Open a PDF 01/30/2024
Dual Special Needs Plan (D-SNP) 2024 Step Therapy Policy Open a PDF 01/30/2024
Duchenne Muscular Dystrophy (DMD) - Amondys 45 (casimersen), Emflaza (deflazacort), Elevidys (delandistrogene moxeparvovec-rokl), Exondys 51 (eteplirsen), Viltepso (vilotarsen) and Vyondys 53 (golodirsen) Open a PDF 01/02/2024
Enbrel (etanercept) – for Ankylosing Spondylitis, Juvenile Idiopathic Arthritis, Plaque Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis Open a PDF 12/06/2023
Generic Advantage Program / MAC Penalty Open a PDF 07/10/2023
Growth Hormone Policy Open a PDF 12/06/2023
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 12/06/2023
Hemgenix (etranacogene dezaparvovec-drlb) Open a PDF 2/14/2023
Hemlibra (emicizumab-kxwh) Open a PDF 12/06/2023
Showing 1– 25 of 62 Results

 

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