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.

 

*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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Showing 1– 25 of 56 Results
Title Last Updated
Aduhelm (aducanumab-avwa) Policy Open a PDF 12/12/2022
Alpha-1 Antitrypsin Therapy (AAT) Open a PDF 5/5/2022
Antihemophilic Agents (For Managed Medicaid and HARP) Open a PDF 1/11/2023
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 12/22/2022
Blood Modifiers Open a PDF 1/9/2023
Botulinum Toxin (Botox, Dysport, Myobloc, Xeomin) – For Medicaid Managed Care Essential Plan and Child Health Plus Open a PDF 9/22/2022
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 11/17/2022
Cimzia (Certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis and Rheumatoid Arthritis Open a PDF 1/1/2023
Clinical Review Prior Authorization - Medical Benefit (Healthcare Professional Administration Only) Cablivi, Ceprotin, Hydroxyprogesterone, Krystexxa, Lemtrada, Leqvio, NPlate, Ocrevus, Saphnelo, Spravato, Sunlenca, Trogarzo, Tysabri, Tzield, Vabysmo, Zoladex, or any other medical agent Open a PDF 1/19/2023
Clinical Review Prior Authorization Rx (CRPA) Open a PDF 1/9/2023
Compounded Drug Products Open a PDF 1/25/2023
Coronavirus (COVID-19) Impacted Drug Therapies (Hydroxychloroquine, Molnupiravir, Paxlovid, Stromectol) Open a PDF 8/22/2022
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 1/1/2023
Generic Advantage Program / MAC Penalty Open a PDF 5/11/2022
Growth Hormone Open a PDF 2/10/2022
Headache Disorders Open a PDF 7/14/2022
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 1/10/2023
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 1/1/2023
Immune Checkpoint Inhibitor (CPI) Clinical Review Prior Authorization (CRPA) (Bavencio, Imfinzi, Imjudo, Jemperli, Keytruda, Libtayo, Opdivo, Tecentriq, and Yervoy) Open a PDF 1/1/2023
Inborn Errors of Metabolism & Rare Genetic Diseases (Health Professional Administration/Medical Benefit) - 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, Kanuma (sebelipase alfa), Kuvan, Javygtor and generic sapropterin, 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), 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 1/1/2023
Infertility Medications Open a PDF 12/15/2022
Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs - (Actemra - tocilizumab (Medical or Rx), Cibinqo - abrocitinib (Rx), Cosentyx - secukinumab (Rx), Entyvio – vedolizumab (Medical), Ilumya – tildrakizumab-asmn (Medical), Kevzara – sarilumab (Rx), Kineret - anakinra (Rx), Olumiant – baricitinib (Rx), Orencia - abatacept (Medical or Rx), Otezla - apremilast (Rx), Rinvoq – upadacitinib (Rx), Siliq – brodalumab (Rx), Skyrizi – risankizumab-rzaa (Rx), Simponi - golimumab (Medical or Rx), Sotyktu (deucravacitinib) (Rx), Spevigo (spesolimab-sbzo) (Rx), Taltz – ixekizumab (Rx), Tremfya – guselkumab (Medical or Rx), Xeljanz and Xeljanz XR- tofacitinib and tofacitinib ER (Rx), Zeposia- ozanimod (Rx)) Open a PDF 1/1/2023
Showing 1– 25 of 56 Results

 

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