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.

As of April 1, 2023, members enrolled in Univera MyHealth and Univera MyHealth Plus receive their prescription medications 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 51– 75 of 79 Results
Title Last Updated
Oncology Biosimilar Drug Policy - (Avastin (bevacizumab) and Alymsys (bevacizumab-maly), Herceptin (trastuzumab), Herceptin Hylecta (trastuzumab and hyaluronidase-oysk), Hercessi (trastuzumab-strf), Jobevne (bevacizumab-mwgd) Ogivri (trastuzumab-dkst), Ontruzant (trastuzumab-dttb), and Herzuma (trastuzumab-pkrb), Rituxan (rituximab), Rituxan Hycela (rituximab hyaluronidase), Riabni (rituximab-arrx) and Vegzelma (bevacizumab-adcd)) – Medical Benefit Open a PDF 01/09/2026
Oncology Clinical Review Prior Authorization (CRPA) Medical Drug Policy (Abraxane, Adcetris, Adstiladrin, Amtagvi, Anktiva, Arzerra, Asparlas, Avgemsi, Axtle, Beizray, Beleodaq, Belrapzo, Bendamustine HCL, Bendeka, Besponsa, Bilprevda, Bispecific T-Cell Engagers (BiTE), Bizengri, Blenrep, Blincyto, Bomyntra, Boruzu, Camcevi, Cinvanti, Colimvi, Cyramza, Danyelza, Darzalex., Darzalex Faspro, Datroway, Docivyx, Elahere, Elitek, Elrexfio, Elzonris, Empliciti, Emrelis, Enhertu, Epkinly, Erwinaze, Focinvez, Folotyn, Fosaprepitant, Fyarro, Gazyva, Hepzato Kit, Imdelltra, Infugem, Inlexzo, Istodax, Ivra, Jelmyto, Kadcyla, Kimmtrak, Kyprolis, Kyxata, Lartruvo, Leuprolide Acetate Depot, Lumoxiti, Lunsumio, Lutrate Depot, Lymphir, Lynozyfic, Margenza, Monjuvi, Mylotarg, Niktimvo, Omisirge, Oncaspar, Onivyde, Osenvelt, Paclitaxel protein-bound particles, Padcev, Pedmark, Pemfexy, Pemrydi, Phesgo, Polivy, Portrazza, Posfrea, Poteligeo, Pralatrexate, Provenge, Romidepsin, Rybrevant, Rybrevant Faspro, Rylaze, Rytelo, Sarclisa, Talvey, Tecelra, Tecvayli, Temsirolimus, Tepylute, Tivdak, Torisel, Treanda, Trodelvy, Vectibix, Vivimusta, Vyloy, Vyxeos, Wyost, Xgeva, Yondelis, Zaltrap, Zepzelca, Ziihera, Zusduri, & Zynlonta) (Health Professional Administered) - Medical Benefit Open a PDF 01/06/2026
Oncology CRPA (Self-Administration) (Abiraterone 500 mg tablet, Afinitor, Afinitor Disperz, Akeega, Alecensa, Alunbrig, Augtyro, Avmapki Fakzynja co-pack, Ayvakit, Balversa, Besremi, (NOTE: both Rx and Medical benefit drug), Bexarotene Capsules, Bosulif, Braftovi, Brukinsa, Cabometyx, Calquence, Caprelsa, Cometriq, Copiktra, Cotellic, Danziten, Dasatinib, Daurismo, Ensacove, Erivedge, Erleada, Erlotinib, Everolimus tablets or suspension), Exkivity, Fotivda, Fruzaqla, Gavreto, Gefitinib, Gilotrif, Gomekli, Hemady, Hernexeos, Ibrance, Ibtrozi, Iclusig, Idhifa, Imbruvica (tablets or suspension), Imkeldi suspension, Inqovi, Inluriyo, Inlyta, Inrebic, Iressa, Itovebi, Iwilfin, Jakafi, Jaypirca, Kisqali, Komzifti, Koselugo, Krazati, Lapatinib, Lazcluze, Lenvima, Lonsurf, Lorbrena, Lumakras, Lynparza tablets, Lytgobi, Mekinist, Mektovi, Mercaptopurine oral suspension, Modeyso, Nerlynx, Nexavar, Nilotinib, Nilotinib d-tartrate, Ninlaro, Nubeqa, Odomzo, Ogsiveo, Ojemda, Ojjaara, Onureg, Orgovyx, Orserdu, Pazopanib, Pemazyre, Phyrago, Piqray, Pomalyst, Purixan, Qinlock, Retevmo, Revuforj, Rezlidhia Rezurock, Romvimza, Rozlytrek, Rubraca, Rydapt, Scemblix, Soltamox, Sorafenib, Sprycel, Stivarga, Sutent, Tabrecta, Tafinlar, Tagrisso, Talzenna, Tarceva, Targretin capsules, Targretin gel, Tasigna, Tazverik, Tepmetko, Tibsovo, Torpenz, Truqap, Tukysa, Turalio, Tykerb, Valchlor, Vanflyta, Venclexta, Verzenio, Vitrakvi, Vizimpro, Vonjo, Voranigo, Votrient, Welireg, Xalkori, Xermelo, Xospata, Xpovio Xtandi, Yonsa, Zejula, Zelboraf, Zolinza, Zydelig, Zykadia, Zytiga) - Rx Benefit Open a PDF 01/15/2026
Opioid Management Health and Safety Program - (Concurrent use of Opioid/Buprenorphine Products, Extended-release (long-acting) opioids, Morphine Milligram Equivalents (MME), Levorphanol, Opioid-naïve ADULT 7-day supply for first FOUR fills limit, Opioid-naïve PEDIATRIC 3-day supply for first FOUR fills limit, Opioid Cough & Cold medicines, Opioids drugs requiring Step Therapy, Prolate Solution & Generic oxycodone-APAP 100-300mg/5ml, Prolate tablets, Nalocet, & generic oxycodone-APAP 5mg/300mg and oxycodone-APAP 10mg/300mg & oxycodone-APAP 2.5mg/300mg, and Roxybond Open a PDF 05/21/2025
Osteoporosis Drug Policy – (Bildyos, Bonsity, calcitonin salmon injection, Conexxence, Evenity®, Forteo®, Jubbonti, Miacalcin injection®, Ospomyv, Prolia®, Stoboclo (denosumab-bmwo), Teriparatide, Tymlos®) Rx Benefit (Self-Administered) & Medical Benefit (Health Professional Administered) Open a PDF 01/23/2026
Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp) Open a PDF 05/08/2025
Papzimeos™ (zopapogene imadenovec-drba) Drug Policy Open a PDF 01/16/2026
Parkinson’s Disease Drug Policy – (Self Administration) - Rx Benefit OR (Health Professional Administered) - Medical Benefit - (Apokyn & apomorphine hydrochloride injection (Rx), Gocovri - amantadine ER capsules (Rx), Inbrija - levodopa inhalation (Rx), Mirapex ER and pramipexole ER (Rx), Neupro - rotigotine patch (Rx), Nourianz - istradefylline tablets (Rx), Nuplazid - pimavanserin tablets & capsules (Rx), Onapgo (apomorphine) (Rx & Medical), Osmolex - amantadine ER tablet (Rx), Rytary and Crexont - carbidopa/levodopa ER capsule (Rx), Vyalev (foscarbidopa/foslevodopa injection) (Rx & Medical), Xadago (safinamide mesylate), Zelapar ODT - Selegiline Hydrochloride (L-Deprenyl) tablet (Rx) Open a PDF 01/01/2026
Patient Protection and Affordable Care Act (PPACA) - Preventive Items and Services Open a PDF 01/23/2026
Pulmonary Hypertension (PH) Drug Policy - Adcirca (tadalafil (including Alyq)(Rx)), Adempas (riociguat (Rx)), epoprostenol (Medical)), Flolan, Letairis (ambrisentan (Rx)), Liqrev, Opsumit (macitentan (Rx)), Opsynvi (macitentan & tadalafil (Rx)), Orenitram (treprostinil (Rx)), Remodulin (treprostinil (Medical)), Revatio (sildenafil (Rx)), Tadliq (Rx)), Tracleer (bosentan (Rx)), Tyvaso (treprostinil) inhalation (Rx), Tyvaso DPI (Rx)), Uptravi (selexipag) Rx)), Veletri (Medical), Ventavis (iloprost) inhalation (Medical)), Winrevair (sotatercept) (Rx & Medical)), & Combination Therapy (Ambrisentan and tadalafil) Open a PDF 01/01/2026
Qalsody (tofersen) Drug Policy (Health Professional Administered) - Medical Benefit Open a PDF 01/01/2026
Quantity Limit Open a PDF 11/13/2025
Rare Diseases CRPA Policy (Medical and Rx Benefits) - (Actimmune (Medical & Rx), Adzynma (Medical), Aldurazyme (Medical), Arcalyst (Rx), Bkemv (Medical), Bylvay (Rx), Camzyos (Rx), Crenessity (Rx), Cuprimine and generic penicillamine capsules (Rx), Cuvrior (Rx), Daybue (Rx), Empaveli (Rx), Enjaymo (Medical), Enspryng (Rx or Medical), Epysqli (Medical), Evkeeza (Medical), Fabhalta (Rx), Filspari (Rx), Firdapse (Rx), Galzin (Rx), Gamifant (Medical), Hyftor 0.2% gel (Rx), Ilaris (Medical), Increlex (Rx), Isturisa (Rx), Joenja (Rx), Juxtapid (Rx), Keveyis (Rx), Korlym (Rx), Livmarli (Rx), Luxturna (Medical), Myalept (Rx), Mycapssa (Rx), Ormalvi (Rx), Piasky (Medical), Procysbi (Rx), Pyrukynd (Rx), Reblozyl (Medical), Recombinant (Rx), Recorlev (Rx), Rethymic (Medical), Revcovi - (Medical & Rx), rh-IGF-1 (Rx), Ryplazim (Medical & Rx), Rystiggo (Medical), Sandostatin LAR and octreotide intramuscular injection (Rx & Medical), Scenesse (Medical), Signifor LAR (Medical), Signifor SC (Rx), Skyclarys (Rx), Skysona (Medical), Sohonos (Rx), Soliris 2mg & 10mg (Medical), Somavert (Rx), Sylvant (Medical), Syprine, generic trientine capsules (Rx), Tarpeyo (Rx), Tavneos (Rx), Tepezza (Medical), Thiola, Thiola EC, and generic tiopronin (Rx), Tryngolza (Rx), Tzield (Medical), Ultomiris (Medical), Uplizna (Medical), Vanrafia, (Rx), Venxxiva (Rx), Veopoz (Medical), Vijoice (Rx), Voxzogo (Rx), Voydeya (Rx), Vyjuvek (Medica & Rxl), Vyvgart (Medical), Vyvgart Hytrulo (Medical), Xolremdi (Rx), Yorvipath (Rx), Zevaskyn (Medical), Zilbrysq (Rx), Zokinvy (Rx), Ztalmy (Rx), Zynteglo (Rx)) Open a PDF 01/15/2026
Remicade® (infliximab), Infliximab, Renflexis® (infliximab-abda), Avsola® (infliximab-axxq), Inflectra® (infliximab-dyyb) - (Health Professional Administered) - Medical Benefit Open a PDF 01/23/2026
Repository Corticotropin Injection (Medical & Rx Benefit) (Acthar HP and Purified Cortrophin gel) - for Infantile Spasms, Multiple Sclerosis Exacerbations Open a PDF 11/19/2025
Respiratory Syncytial Virus (RSV) Prophylaxis Drug Policy (Health Professional Administered) - Medical Benefit Open a PDF 11/19/2025
Rezdiffra (resmetirom) Drug Policy (Self Administration) - Rx Benefit Open a PDF 01/01/2026
Ryoncil (remestemcel-l-rknd) Drug Policy - (Health Professional Administered) - Medical Benefit Open a PDF 11/19/2025
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), Xromi (Rx)) Open a PDF 11/19/2025
Site of Care Redirection for Medical Specialty Drug Administration Policy Open a PDF 01/01/2026
Spinal Muscular Atrophy (SMA) - Medical Benefit (Evrysdi (risdiplam), Spinraza (nusinersen), Zolgensma (onasemnogene abeparovec-xioi)) Open a PDF 11/19/2025
Step Therapy Drug Policy Open a PDF 01/01/2026
Testosterone Drug Policy (Testopel, Aveed, & Azmiro) (Health Professional Administered) - Medical Benefit Open a PDF 01/21/2026
Tezspire™ (tezepelumab-ekko subcutaneous injection) Open a PDF 12/22/2025
Ustekinumab Drug Policy (Imuldosa [ustekinumab-srlf], Otulfi [ustekinumab-aauz], Pyzchiva [ustekinumab-ttwe], Pyzchiva [ustekinumab-ttwe][Cordavis]], (Selarsdi [ustekinumab-aekn], Stelara [ustekinumab], Steqeyma [ustekinumab-stba], ustekinumab [Janssen Biotech], ustekinumab-aekn, ustekinumab-ttwe [Quallent], Wezlana [ustekinumab-auub][Optum-Nuvalia]], Yesintek [ustekinumab-kfce]) (Self-Administered & Health Professional Administered) – Rx Benefit & Medical Benefit Open a PDF 01/23/2026
Showing 51– 75 of 79 Results

 

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