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 64 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): Amondys 45 (casimersen), Emflaza (deflazacort), Exondys 51 (eteplirsen), Viltepso (vilotarsen) and Vyondys 53 (golodirsen) Open a PDF 9/22/2022
Cimzia (Certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis and Rheumatoid Arthritis Open a PDF 9/1/2023
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) - (Duexis, fenoprofen tablets, Flector, Licart, Lofena, diclofenac patches, indomethacin capsules, indomethacin suppositories, ketoprofen capsules, Naprelan, naproxen ER, naproxen suspension, Pennsaid, Qmiiz, Relafen DS, Seglentis, Sprix, ketorolac/tromethamine nasal spray, Tivorbex, Vimovo, Vivlodex, meloxicam capsules, Xelstrym, Zipsor, Zorvolex and diclofenac 35 mg capsules) Open a PDF 8/24/2023
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
Pulmonary Hypertension (PH) - Adcirca (tadalafil (including Alyq)(Rx)), Adempas (riociguat (Rx)), epoprostenol (Medical)), Flolan, Letairis (ambrisentan (Rx)), Liqrev, Opsumit (macitentan (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)), & Combination Therapy (Ambrisentan and tadalafil) Open a PDF 6/8/2023
Amyotrophic Lateral Sclerosis (ALS) Policy - (Exservan - riluzole oral film (Rx), Radicava and Radicava ORS - edaravone injection and kit (Rx/Medical), Relyvrio - sodium phenylbutyrate and taurursodiol (Rx), Tiglutik-riluzole oral suspension (Rx), & Qalsody-tofersen (Medical)) Open a PDF 5/30/2023
Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp) Open a PDF 5/11/2023
Repository Corticotropin Injection (Acthar HP and Purified Cortrophin gel) - for Infantile Spasms, Multiple Sclerosis Exacerbations Open a PDF 4/1/2023
Coronavirus (COVID-19) Impacted Drug Therapies (Hydroxychloroquine, Lagevrio (molnupiravir), Paxlovid (nirmatrelvir/ritonavir), Stromectol (ivermectin)) Open a PDF 4/1/2023
Oncology Biosimilar Drug Policy - (Avastin (bevacizumab) and Alymsys (bevacizumab-maly), Herceptin (trastuzumab), Herceptin Hylecta (trastuzumab and hyaluronidase-oysk), Ogivri (trastuzumab-dkst), Ontruzant (trastuzumab-dttb), and Herzuma (trastuzumab-pkrb), Rituxan (rituximab), Rituxan Hycela (rituximab hyaluronidase), Riabni (rituximab-arrx) and Vegzelma (bevacizumab-adcd) (Medical)) Open a PDF 3/20/2023
Alpha-1 Antitrypsin Therapy (AAT) Open a PDF 3/20/2023
Hereditary Angioedema (HAE) For Berinert, Cinryze, Firazyr, Icatibant Haegarda, Kalbitor, Orladeyo, Ruconest, Sajazir, and Takhzyro Open a PDF 3/15/2023
Hemgenix (etranacogene dezaparvovec-drlb) Open a PDF 2/14/2023
Hemlibra (emicizumab-kxwh) Open a PDF 12/15/2022
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 12/1/2023
Botulinum Toxin (Botox, Daxxify, Dysport, Myobloc, Xeomin) – for Medicaid Managed Care, Essential Plan, Child Health Plus, and Dual Eligible Special Needs Plan (D-SNP) Open a PDF 12/1/2023
Antihemophilic Agents (for Medicaid Managed Care, HARP, & D-SNP) Open a PDF 12/1/2023
Oncology Clinical Review Prior Authorization Rx (Self Administration) - (Abiraterone 500 mg tablet, Afinitor (everolimus), Akeega (niraparib tosylate monohydrate and abiraterone acetate), Alecensa (alectinib), Alunbrig (brigatinib), Ayvakit (avapritinib), Balversa (erdafitinib), Besremi (ropeginterferon alfa-2b-njft), (NOTE: both Rx and Medical benefit drug), Bosulif (bosutinib), Braftovi (encorafenib), Brukinsa (zanubrutinib), Cabometyx (cabozantinib tablets), Calquence (acalabrutinib), Caprelsa (vandetanib), Cometriq (cabozantinib capsules), Copiktra (duvelisib), Cotellic (cobimetinib), Daurismo (glasdegib), Disperz (everolimus), Erivedge (vismodegib), Erleada (apalutamide), Exkivity (mobocertinib), Fotivda (tivozanib), Fruzaqla (futquintinib), Gavreto (pralsetinib), Gilotrif (afatinib), Hemady (dexamethasone), Ibrance (palbociclib), Iclusig (ponatinib), Idhifa (enasidenib), Imbruvica (ibrutinib), Inlyta (axitinib), Inqovi (decitabine/cedazuridine), Inrebic (fedratinib), Iressa (gefitinib), Jakafi (ruxolitinib), Jaypirca (pirtobrutinib), Kisqali and Kisqali Femara Co-Pack (ribociclib and ribociclib/letrozole), Koselugo (selumetinib), Krazati (adagrasib), Lenvima (lenvatinib), Lonsurf (trifluridine and tipiracil), Lorbrena (lorlatinib), Lumakras (sotorasib), Lynparza tablets (olaparib tablets), Lytgobi (futibatinib), Mekinist (trametinib), Mektovi (binimetinib), Nerlynx (neratinib), Nexavar (sorafenib), Sorafenib (generic Nexavar), Ninlaro (ixazomib), Nubeqa (darolutamide), Odomzo (sonidegib), Ojjaara (momelotinib), Onureg (oral azacitidine), Orgovyx (relugolix), Orserdu (elacestrant), Pemazyre (pemigatinib), Piqray (alpelisib), Pomalyst (pomalidomide), Purixan (6-mercaptopurine), Qinlock (ripretinib), Retevmo (selpercatinib), Revlimid (lenalidomide), Rezlidhia (olutasidenib), Rezurock (belumosudil), Rozlytrek (entrecetinib), Rubraca (rucaparib), Rydapt (midostaurin), Scemblix (asciminib), Soltamox (tamoxifen citrate), Sprycel (dasatinib), Stivarga (regorafenib), Sutent (sunitinib), Tabrecta (capmatinib), Tafinlar (dabrafenib), Tagrisso (osimertinib), Talzenna (talazoparib), Tarceva (erlotinib), Targretin capsules (bexarotene capsules), Targretin gel (bexarotene gel), Tasigna (nilotinib), Tazverik (tazemetostat), Tepmetko (tepotinib), Tibsovo (ivosidenib), Tukysa (tucatinib), Turalio (pexidartinib), Valchlor (mechlorethamine), Vanflyta (quizartinib), Venclexta (venetoclax), Verzenio (abemaciclib), Vitrakvi (larotrectinib), Vizimpro (dacomitinib), Vonjo (pacritinib), Votrient (pazopanib), Welireg (belzutifan), Xalkori (crizotinib), Xermelo (telotristate ethyl), Xospata (gileritinib), Xpovio (selinexor), Xtandi (enzalutamide), Yonsa (abiraterone acetate, micronized), Zejula (niraparib), Zelboraf (vemurafenib), Zolinza (vorinostat), Zydelig (idelalisib), Zykadia (ceritinib), Zytiga (abiraterone acetate)) Open a PDF 12/01/2023
Attention Deficit Hyperactivity Disorder (ADHD) Policy - Adhansia XR, Azstarys, Daytrana, dextroamphetamine/amphetamine ER capsule (generic Mydayis), Dyanavel XR, methylphenidate patch (generic Daytrana), Mydayis and Xelstrym, Adzenys XR ODT (amphetamine ER ODT), Adzenys ER (and generic amphetamine ER suspension), Cotempla XR ODT (methylphenidate ER ODT), Dyanavel XR (amphetamine ER suspension), Quillichew ER (methylphenidate ER chewable tablets), Quillivant (methylphenidate ER suspension), Desoxyn and generic methamphetamine (Rx), Jornay PM - methylphenidate ER capsules, Qelbree – viloxazine ER capsules Open a PDF 12/01/2023
Clinical Review Prior Authorization Rx (CRPA) Open a PDF 12/01/2023
Dual Special Needs Plan (D-SNP) 2023 Step Therapy Policy Open a PDF 12/01/2023
Dual Special Needs Plan (D-SNP) 2023 Prior Authorization Policy Open a PDF 12/01/2023
Osteoporosis - Evenity® (romosozumab-aqqg), Forteo® (teriparatide), Teriparatide, Prolia® (denosumab), Tymlos® (abaloparatide), Miacalcin injection®, calcitonin salmon injection Open a PDF 12/01/2023
Medicare Part D 2023 Prior Authorization Policy Open a PDF 11/30/2023
Showing 1– 25 of 64 Results

 

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