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 1– 25 of 74 Results
Title Last Updated
Oncology CRPA (Health Professional Administered) – Medical Benefit (Abecma, Abraxane, Adcetris, Adstiladrin, Amtagvi, Anktiva, Arzerra, Asparlas, Beizray, Beleodaq, Belrapzo, Bendamustine HCL, Bendeka, Besponsa, Bispecific T-Cell Engagers (BiTE), Blincyto, Boruzu, 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, Ivra, Jelmyto, Kadcyla, Kimmtrak, Kymriah, Kyprolis, Lartruvo, Leuprolide Acetate Depot, Lumoxiti, Lunsumio, Margenza, Monjuvi, Mylotarg, Niktimvo, Omisirge, Oncaspar, Onivyde, Paclitaxel protein-bound particles, Padcev, Pedmark, Pemfexy, Pemrydi, Phesgo, Polivy, Portrazza, Posfrea, Poteligeo, Pralatrexate, Provenge, Romidepsin, Rybrevant, Rylaze, Rytelo, Sarclisa, Talvey, Tecartus, Tecelra, Tecvayli, Temsirolimus, Tepylute, Tivdak, Torisel, Treanda, Trodelvy, Vectibix, Vivimusta, Vyloy, Vyxeos, Wyost, Xgeva, Yescarta, Yondelis, Zaltrap, Zepzelca, & Zynlonta) Open a PDF 05/21/2025
Clinical Review Prior Authorization (CRPA) Rx Drug Policy Open a PDF 05/21/2025
Low Clinical Impact for Rx Drugs Policy Open a PDF 05/21/2025
Chimeric Antigen Receptor T Cell (CAR-T) Therapy – (Medical Benefit) (Health Professional Administered) - (Abecma, Aucatzyl, Breyanzi, Carvykti, Kymriah, Tecartus, & Yescarta) Open a PDF 05/21/2025
Site of Care Redirection for Medical Specialty Drug Administration Policy Open a PDF 05/21/2025
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
Immune Checkpoint Inhibitor (CPI) (Medical Benefit) (Health Professional Administered) - (Bavencio, Imfinzi, Imjudo, Jemperli, Keytruda, Libtayo, Loqtorzi, Opdivo, Optivo Qvantig, Opdualag, Tecentriq, Tecentriq Hybreza, Tevimbra, Yervoy, and Zynyz) Open a PDF 05/19/2025
Inborn Errors of Metabolism Policy (Rx & Medical Benefit) – (Attruby, 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 05/19/2025
Quantity Limit Open a PDF 05/15/2025
Blood Modifiers - (Cosela, Fulphila, Fylnetra, Granix, Neupogen, Nivestym, Nypozi, Nyvepria, Releuko, Rolvedon, Stimufend, Ziextenzo) - Rx (Self Administration) & Medical Benefits (Health Professional Administered) Open a PDF 05/15/2025
Kebilidi (eladocagene exuparvovec-tneq) (Health Professional Administered) - Medical Benefit Open a PDF 05/08/2025
Xolair (omalizumab) Drug Policy Open a PDF 05/08/2025
Ustekinumab (Stelara [ustekinumab], Yesintek [ustekinumab-kfce], Steqeyma [ustekinumab-stba], Wezlana [ustekinumab-auub], ustekinumab-ttwe, Otulfi [ustekinumab-aauz], Pyzchiva [ustekinumab-ttwe]) Open a PDF 05/08/2025
Rezdiffra (resmetirom) Drug Policy Open a PDF 05/08/2025
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), 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), Venxxiva Rx, Veopoz (Medical), Vijoice (Rx), Voxzogo (Rx), Voydeya (Rx), Vyjuvek (Medical), Vyvgart (Medical), Vyvgart Hytrulo (Medical), Xolremdi (Rx), Yorvipath (Rx), Zilbrysq (Rx), Zokinvy (Rx), Ztalmy (Rx), Zynteglo (Rx)) Open a PDF 05/08/2025
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 05/08/2025
Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp) Open a PDF 05/08/2025
Oncology CRPA (Self-Administration) - Rx Benefit - (Abiraterone 500 mg tablet, Afinitor, Afinitor Disperz, Akeega, Alecensa, Alunbrig, Augtyro, Ayvakit, Balversa, Besremi, (NOTE: both Rx and Medical benefit drug), Bexarotene Capsules, Bosulif, Braftovi, Brukinsa, Cabometyx, Calquence, Caprelsa, Cometriq, Copiktra, Cotellic, Danziten, Dasatinib, Daurismo, Disperz, Erivedge, Erleada, Erlotinib, Everolimus tablets or suspension), Exkivity, Fotivda, Fruzaqla, Gavreto, Gefitinib, Gilotrif, Gomekli, Hemady, Ibrance, Iclusig, Idhifa, Imbruvica (tablets or suspension), Imkeldi suspension, Inqovi, Inlyta, Inrebic, Iressa, Itovebi, Iwilfin, Jakafi, Jaypirca, Kisqali, Koselugo, Krazati, Lapatinib, Lazcluze, Lenvima, Lonsurf, Lorbrena, Lumakras, Lynparza tablets, Lytgobi, Mekinist, Mektovi, Mercaptopurine oral suspension, Nerlynx, Nexavar, Ninlaro, Nubeqa, Odomzo, Ogsiveo, Ojemda, Ojjaara, Onureg, Orgovyx, Orserdu, Pazopanib, Pemazyre, Piqray, Pomalyst, Purixan, Qinlock, Retevmo, Revuforj, Rezlidhia Rezurock, Romvimza, Rozlytrek, Rubraca, Rydapt, Scemblix, Soltamox, 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) Open a PDF 05/08/2025
Off-Label Use of FDA Approved Drugs Open a PDF 05/08/2025
Monoclonal Antibodies for the Treatment of Hemophilia – (Health Professional Administered) Medical Benefit & (Self-Administered) Rx Benefit - (Alhemo, Hemlibra and Hympavzi) Open a PDF 05/08/2025
Lyfgenia (lovotibeglogene autotemcel) Drug Policy - Medical Benefit Open a PDF 05/08/2025
Intravenous Immune Globulin (IVIG) & Sub-Cutaneous Immune Globulin (SCIG) Therapy – (Health Professional Administered) Rx & Medical Benefit (Alyglo, Asceniv, Bivigam, Cutaquig, Cuvitru, Flebogamma, Gammagard Liquid, Gammagard S/D powder, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, & Xembify) Open a PDF 05/08/2025
Intravenous Iron Replacement Products Policy - Medical Benefit Open a PDF 05/08/2025
Interleukin Antagonists for Asthma and Other Conditions - (Health Professional Administered) Medical Benefit & (Self-Administered) Rx Benefit - (Adbry, Cinqair, Dupixent, Ebglyss, Fasenra, Nemluvio, & Nucala) Open a PDF 05/08/2025
Remicade® (infliximab), Infliximab, Renflexis® (infliximab-abda), Avsola® (infliximab-axxq), Inflectra® (infliximab-dyyb) - (Health Professional Administered) - Medical Benefit Open a PDF 05/08/2025
Showing 1– 25 of 74 Results

 

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