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– 64 of 64 Results
Title Last Updated
Rare Diseases CRPA Policy - (Actimmune - Interferon Gamma - 1B (Medical & Rx), Aldurazyme - laronidase (Medical), Arcalyst - rilonacept (Rx), Bylvay - odevixibat (Rx), Camzyos - mavacamten capsules (Rx), Cuprimine and generic penicillamine capsules (Rx), Cuvrior - trientine (Rx), Daybue - trofinetide (Rx)Empaveli - pegcetacoplan (Medical & Rx), Enjaymo - sutimlimab-jome (Medical), Enspryng - satralizumab-mwge injection (Rx or Medical), Evkeeza - evinacumab-dgnb (Medical), Filspari - sparsentan (Rx), Firdapse - amifampridine (Rx), Gamifant - emapalumab-lzsg (Medical), Hyftor 0.2% gel - sirolimus topical gel (Rx), Ilaris - canakinumab (Medical), Increlex - mecasermin, Isturisa - osilodrostat tablets (Rx), Joenja – leniolisib (Rx), Juxtapid - lomitapide capsules (Rx), Keveyis - dichlorphenamide (Rx), Korlym - mifepristone tablets (Rx), Lanreotide Acetate Injection (Medical & Rx), Livmarli - maralixibat (Rx), Luxturna - voretigene neparvovec-rzyl (Medical), Myalept - metreleptin (Rx), Mycapssa octreotide acetate (Rx), Procysbi - cysteamine capsules and packets (Rx), Pyrukynd - mitapivat tablets (Rx), Reblozyl -luspatercept-aamt (Medical), Recorlev - levoketoconazole (Rx), Rethymic - allogeneic processed thymus tissue-agdc (Medical), Revcovi - elapegademase-lvlr (Medical & Rx), Ruzurgi - amifampridine (Rx), Ryplazim - plasminogen, human-tvm (Medical & Rx), Sandostatin LAR (Rx & Medical), Scenesse - afamelanotide (Medical), Signifor LAR - pasireotide (Medical), Signifor SC - pasireotide solution (Rx), Skyclarys - omaveloxolone (Rx), Skysona-elivaldogene autotemcel (Medical), Soliris - eculizumab (Medical), Somavert - pegvisomant (Rx), Sylvant - siltuximab (Medical), Syprine, generic trientine capsules (Rx), Tarpeyo - budesonide delayed release capsules (Rx), Tavneos - avacopan (Rx), Tepezza - teprotumumab-trbw (Medical), Thiola, Thiola EC and generic tiopronin (Rx), Ultomiris - ravulizumab-cwvz injection (Medical), Tzield - teplizumab-mzwv (Medical), Uplizna - inebilizumab-cdon (Medical), Vijoice - alpelisib (Rx), Voxzogo - vosoritide (Rx), Vyvgart - efgartigimod alfa-fcab (Medical), Zokinvy - lonafarnib (Rx), Ztalmy -ganaxolone (Rx), Zynteglo - betibeglogene (Rx)) Open a PDF 11/17/2023
Remicade® (infliximab), Infliximab, Renflexis® (infliximab-abda) Open a PDF 08/24/2023
Repository Corticotropin Injection (Acthar HP and Purified Cortrophin gel) - for Infantile Spasms, Multiple Sclerosis Exacerbations Open a PDF 4/1/2023
Respiratory Syncytial Virus (RSV) Prophylaxis Open a PDF 10/26/2023
Sickle Cell Disease Management - Adakveo (crizanlizumab-tmca (Medical)), Endari (L-glutamine oral powder (Rx)), Oxbryta (voxelotor (Rx) for 300 mg Tablets, 500mg Tablets and 300mg Tablets for Oral Suspension, Siklos (hydroxyurea tablets (Rx)) Open a PDF 8/16/2023
Spinal Muscular Atrophy (SMA) – Evrysdi (risdiplam), Spinraza (nusinersen), Zolgensma (onasemnogene abeparovec-xioi) Open a PDF 07/01/2023
Stelara (ustekinumab) – for Crohn’s Disease, Plaque Psoriasis and Psoriatic Arthritis Open a PDF 08/24/2023
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, Insulin Aspart, Kazano, Kombiglyze, Latanoprost/PF, Latuda, Livalo, Lonhala Magnair 25 mcg Refill & Starter, Luliconazole, Luzu, Lyuzeh, Metformin ER (generics of Fortamet and Glumetza), Metformin HCl 625 mg, Motegrity, Naftin Gel, Nesina, Norgesic Forte, Noritate, Novolog, 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, Savaysa, 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 11/10/2023
Tezspire™ (tezepelumab-ekko subcutaneous injection) Open a PDF 07/13/2023
Viscosupplementation with Hyaluronic Acid Open a PDF 08/24/2023
Weight Management - Contrave, Orlistat, Qsymia, Saxenda, Wegovy, Xenical, Zepbound Open a PDF 11/29/2023
Xiaflex (collagenase clostridium histolyticum) Policy Open a PDF 08/24/2023
Xolair (omalizumab) Open a PDF 07/13/2023
Zulresso (brexanolone injection) for Postpartum Depression Open a PDF 08/24/2023
Showing 51– 64 of 64 Results

 

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