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.

Make a Comment

We invite practitioners to review & comment on our policies.

Showing 51– 57 of 57 Results
Title Last Updated
Step Therapy Drug Policy - Acyclovir 5% cream, Adapalene 0.1% (Lotion, Soln, Swab), Adlyxin, Admelog, Adlarity, AirDuo Digihaler, AirDuo Respiclick, Alogliptin, Alogliptin/metformin, Alogliptin/pioglitazone, Alvesco, Amitiza, Amzeeq, Anzemet, Apidra, Armonair Digihaler, Aspart Insulin, Atripla, Aczone 7.5%, Aubagio, Bafiertam, Belsomra, Blood Glucose Meters and Test Strips, Brexafemme, Breztri, Budesonide/Formoterol, Bydureon, Byetta, Caplyta, Clindagel 75 mL, Clindamycin 1% Gel 75 mL (Oceanside & Solaris), Daliresp, Dapsone 7.5%, Dayvigo, Denavir 1% Cream, Dexilant, Dexlansoprazole DR, Differin 0.1% Lotion, Doryx, Doxycycline hyclate DR, Drizalma Sprinkle, Duaklir Pressair, Ecoza, Edarbi, Edarbyclor, Edluar, Emsam, Ertaczo, Estring, Eucrisa Ointment, Fanapt, Fiasp, Fluticasone Propionate HFA, Fluticasone-Vilanterol, Fluticasone-salmeterol HFA, Forfivo XL 450mg, Fortamet, Gelnique, Gemtesa, Glumetza, Ibsrela, Kazano, Kombiglyze, Konvomep, Latuda, Livalo, Lonhala Magnair 25 mcg Refill & Starter, Luliconazole, Luzu, Metformin ER (generics of Fortamet and Glumetza), Metformin HCl 625 mg, Motegrity, Naftin Gel, Nesina, Norgesic Forte, Noritate, Novolog Mix 70/30, Omeprazole/Sodium Bicarbonate Packets, Onglyza, Onzetra Spray, Orphenadrine/Aspirin/Caffeine, Orphengesic Forte, Oseni, Osphena, Oxistat Lotion, Oxytrol, Ozempic, Pancreaze, Penciclovir 1% Cream, Pertzye, Ponvory, Praluent, Prograf Granules, Pulmicort Flexhaler, Qtern, Quviviq, Rezvoglar, Relistor Tablet, Restasis 0.05%, Restasis Multidose 0.05%, Rexulti, Rhopressa, Rocklatan, Roflumilast, Rybelsus, Savaysa, Sancuso, Savella, Secuado, Sernivo Lotion, Symproic, Tafluprost, Thalitone, Tosymra, Trulicity, Tudorza Pressair, Ultravate Lotion, Veltassa, Venlafaxine ER Tablets, Verdeso, Victoza, Vraylar, Vumerity, Vyzulta, Xadago, Xelpros, Xerese 5%-1% Cream, Xolegel, Yupelri, Zegerid Packets, Zembrace, Zerviate, Zilxi 1.5%, Zioptan, Zolmitriptan Nasal Spray, Zomig Nasal Spray, Zolpimist, Zovirax 5% cream, Zuplenz, Zypitamag Open a PDF 04/24/2023
Synagis® (Palivizumab): Respiratory Syncytial Virus (RSV) Prophylaxis Open a PDF 11/17/2022
Tezspire™ (tezepelumab-ekko subcutaneous injection) Open a PDF 5/1/2023
Viscosupplementation with Hyaluronic Acid Open a PDF 3/20/2023
Weight Management - Contrave, Orlistat, Qsymia, Saxenda, Wegovy, Xenical Open a PDF 5/24/2023
Xolair (omalizumab) Open a PDF 5/11/2023
Zulresso (brexanolone injection) for Postpartum Depression Open a PDF 3/15/2023
Showing 51– 57 of 57 Results

 

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