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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Showing 1– 25 of 55 Results
Title Last Updated
Acthar Gel® (Repository Corticotropin Injection) - for Infantile Spasms, Multiple Sclerosis Exacerbations Open a PDF 5/6/2021
Aduhelm (aducanumab-avwa) Policy Open a PDF 9/1/2021
Alpha-1 Antitrypsin Therapy (AAT) Open a PDF 9/1/2021
Anorexiants; Contrave (naltrexone/bupropion ER), QsymiaTM (phentermine/topiramate ER), Saxenda (liraglutide), Wegovy (semaglutide) and Xenical® (orlistat), Imcivree (setmelanotide) Open a PDF 9/15/2021
Antihemophilic Agents Open a PDF 5/10/2021
Attention Deficit Hyperactivity Disorder (ADHD) Stimulants Policy Open a PDF 9/1/2021
Blood Modifiers Open a PDF 11/1/2021
Botulinum Toxin (Botox, Dysport, Myobloc, Xeomin) – For Medicaid Managed Care Essential Plan and Child Health Plus Open a PDF 12/2/2021
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 11/18/2021
Cimzia (Certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis and Rheumatoid Arthritis Open a PDF 9/16/2021
Clinical Review Prior Authorization (CRPA) Medical Drugs Open a PDF 11/11/2021
Clinical Review Prior Authorization Rx (CRPA) Open a PDF 11/22/2021
Compounded Drug Products Open a PDF 2/11/2021
Coronavirus (COVID-19) Impacted Drug Therapies (azithromycin, chloroquine, hydroxychloroquine, ivermectin, Kaletra, lopinavir/ritonavir, Plaquenil, Stromectol, Zithromax) Open a PDF 9/28/2021
Duchenne Muscular Dystrophy (DMD): Amondys 45 (casimersen), Emflaza (deflazacort), Exondys 51 (eteplirsen), Viltepso (vilotarsen) and Vyondys 53 (golodirsen) Open a PDF 12/3/2021
Enbrel (etanercept) – for Ankylosing Spondylitis, Juvenile Idiopathic Arthritis, Plaque Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis Open a PDF 9/16/2021
Generic Advantage Program / MAC Penalty Open a PDF 6/8/2021
Growth Hormone Open a PDF 11/10/2021
Headache Disorders Open a PDF 10/14/2021
Hemlibra Open a PDF 5/6/2021
Hereditary Angioedema (HAE) Open a PDF 3/9/2021
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 9/16/2021
Immune Checkpoint Inhibitor Clinical Review Prior Authorization (CRPA) (Bavencio, Imfinzi, Jemperli, Keytruda, Libtayo, Opdivo, Tecentriq, Yervoy) Open a PDF 11/15/2021
Inborn Errors of Metabolic Diseases (IEM) Open a PDF 11/1/2021
Infertility Medications Open a PDF 11/19/2021
Showing 1– 25 of 55 Results
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