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.

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We invite practitioners to review & comment on our policies.

Showing 1– 25 of 70 Results
Title Last Updated
Anti-Amyloid Directed Therapies Policy (Aduhelm (aducanumab-avwa) & Leqembi (lecanemab-irmb)) Open a PDF 9/7/2023
Duchenne Muscular Dystrophy (DMD) - Agamree, Amondys 45, Emflaza and generic deflazacort, Exondys 51, Viltepso and Vyondys 53 Open a PDF 5/28/2024
Infertility Medications Open a PDF 12/06/2023
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 12/06/2023
Medicare Part D Formulary Level Cumulative Opioid and Opioid / Buprenorphine POS Edits Open a PDF 11/30/2023
Respiratory Syncytial Virus (RSV) Prophylaxis Open a PDF 11/30/2023
Non-Formulary Medication Exception Review Policy Open a PDF 11/30/2023
Viscosupplementation with Hyaluronic Acid Open a PDF 08/24/2023
Xiaflex (collagenase clostridium histolyticum) Policy Open a PDF 08/24/2023
Generic Advantage Program / MAC Penalty Open a PDF 07/10/2023
Geographic Atrophy Drug Policy (Health Professional Administered) - Medical Benefit (Izervay, Syfovre) Open a PDF 07/01/2024
Clinical Review Prior Authorization (Medical Benefit) - (Briumvi (ublituximab-xiiy) (Medical), Cablivi (caplacizumab-yhdp) (Rx & Medical), Ceprotin (Protein C Concentrate, Human) (Medical), Eylea HD (aflibercept) (Medical), Fensolvi (leuprolide acetate), Hydroxyprogesterone Caproate Injection (Medical), Krystexxa - pegloticase (Medical), Lemtrada - alemtuzumab (Medical), Leqvio - inclisiran (Medical), Nplate - romiplostim (Medical), Ocrevus (ocrelizumab) (Medical), Rebyota - fecal microbiota,live-jslm (Medical), Saphnelo – anifrolumab-fnia (Medical), Spravato – esketamine nasal spray (Medical), Sunlenca (lenacapavir) (Rx & Medical), Supprelin LA (histrelin acetate) (Medical), Syfovre - pegcetacoplan injection (Medical), Triptodur (triptorelin), Trogarzo (ibalizumab-uiyk) (Medical), Trogarzo – ibalizumab-uiyk (Medical), Tysabri (natalizumab) (Medical), Vabysmo - faricimab-svoa (Medical), Zilretta – triamcinolone acetonide extended-release (Medical), Zoladex – goserelin implant (Medical), or any other medical agent) Open a PDF 06/17/2024
Oncology CRPA (Medical Benefit) (Health Professional Administered) – (Abecma, Abraxane, Adcetris, Adstiladrin, Anktiva, Arzerra, Asparlas, Beleodaq, Belrapzo, Bendamustine HCL, Bendeka, Besponsa, Blincyto, Breyanzi, Camcevi, Carvykti, Colimvi, Cyramza, Danyelza, Darzalex., Darzalex Docivyx, Faspro, Elahere, Elitek, Elrexfio, Elzonris, Empliciti, Enhertu, Epkinly, Erwinaze, Folotyn, Fyarro, Gazyva, Hepzato Kit, Imdelltra, Infugem, Istodax, Jelmyto, Kadcyla, Kimmtrak, Kymriah, Kyprolis, Lartruvo, Leuprolide Acetate Depot, Lumoxiti, Lunsumio, Margenza, Monjuvi, Mylotarg, Omisirge, Oncaspar, Onivyde, Paclitaxel protein-bound particles, Padcev, Pedmark, Pemfexy, Pemrydi, Phesgo, Polivy, Portrazza, Poteligeo, Pralatrexate, Provenge, Romidepsin, Rybrevant, Rylaze, Sarclisa, Talvey, Tecartus, Tecvayli, Temsirolimus, Tivdak, Torisel, Treanda, Trodelvy, Vectibix, Vivimusta, Vyxeos, Xgeva, Yescarta, Yondelis, Zaltrap, Zepzelca, & Zynlonta) Open a PDF 06/17/2024
Lyfgenia (lovotibeglogene autotemcel) Drug Policy - Medical Benefit Open a PDF 06/17/2024
Casgevy (exagamglogene autotemcel) Drug Policy - Medical Benefit Open a PDF 06/17/2024
Medicare Part B Step Therapy Drug List Open a PDF 06/13/2024
Hereditary Angioedema (HAE) For Berinert, Cinryze, Firazyr, Icatibant Haegarda, Kalbitor, Orladeyo, Ruconest, Sajazir, and Takhzyro Open a PDF 06/13/2024
Inborn Errors of Metabolism Policy (Rx & Medical Benefit) – (Amvuttra, Brineura, Carbaglu and generic carglumic acid, Cerdelga, Cerezyme, Cholbam, Crysvita, Dojolvi, Elaprase, Elelyso, Elfabrio, Fabrazyme, Galafold, Givlaari, Javygtor and generic sapropterin, Kanuma, Kuvan, Lamzede, Lumizyme, Mepsevii , Naglazyme, Nexviazyme, nitisinone capsule, Nityr, Nulibry, Olpruva, Onpattro, Orfadin, Oxlumo, Palynziq, Pombiliti, Ravicti , Rivfloza, Strensiq, Sucraid, Tegsedi, Vimizim, VPRIV, Vyndaqel, Vyndamax, Wainua, Xenpozyme, Xuriden, Yargesa & Zavesca) Open a PDF 06/11/2024
Coronavirus (COVID-19) Impacted Drug Therapies (Lagevrio (molnupiravir), Paxlovid (nirmatrelvir/ritonavir), Stromectol (ivermectin)) Open a PDF 06/11/2024
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), Tyenne Actemra biosimilar), Xeljanz and Xeljanz XR- tofacitinib and tofacitinib ER (Rx), Zeposia- ozanimod (Rx)) Open a PDF 06/05/2024
Stelara (ustekinumab) – for Crohn’s Disease, Plaque Psoriasis and Psoriatic Arthritis Open a PDF 06/04/2024
Remicade® (infliximab), Infliximab, Renflexis® (infliximab-abda) Open a PDF 06/04/2024
Enbrel (etanercept) – for Ankylosing Spondylitis, Juvenile Idiopathic Arthritis, Plaque Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis Open a PDF 06/04/2024
Cimzia (Certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis and Rheumatoid Arthritis Open a PDF 06/04/2024
Adalimumab (Self-Administered - Rx benefit) (Humira® [adalimumab], Abrilada™[adalimumab-afzb], Amjevita™ [adalimumab-atto], Cyltezo®/ adalimumab-adbm [adalimumab-adbm], Hadlima™ [adalimumab-bwwd], Hulio®/adalimumab-fkjp [adalimumab-fkjp], Hyrimoz®/adalimumab-adaz [adalimumab-adaz], Idacio®/ adalimumab-aacf [adalimumab-aacf], Simlandi® (adalimumab-ryvk), Yuflyma® [adalimumab-aaty], Yusimry™ [adalimumab-aqvh]) Open a PDF 06/04/2024
Showing 1– 25 of 70 Results

 

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