Prescription Drug Polices

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.


*Pharmacy benefit drugs - Univera Healthcare continues to manage the pharmacy benefit for Medicaid Managed Care and Child Health Plus members. Use the Univera Pharmacy Management Drug Policies below.

Make a Comment

We invite practitioners to review & comment on our policies.

Showing 1– 25 of 55 Results
Title Last Updated
Coronavirus (COVID-19) Impacted Drug Therapies (azithromycin, chloroquine, hydroxychloroquine, ivermectin, Kaletra, lopinavir/ritonavir, Plaquenil, Stromectol, Zithromax) Open a PDF 9/28/2021
Enbrel (etanercept) – for Ankylosing Spondylitis, Juvenile Idiopathic Arthritis, Plaque Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis Open a PDF 9/16/2021
Cimzia (Certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis and Rheumatoid Arthritis Open a PDF 9/16/2021
Viscosupplementation with Hyaluronic Acid Open a PDF 9/16/2021
Stelera (Ustekinumab) – for Crohn’s Disease, Plaque Psoriasis and Psoriatic Arthritis Open a PDF 9/16/2021
Spinal Muscular Atrophy (SMA) – Evrysdi (risdiplam), Spinraza (nusinersen), Zolgensma (onasemnogene abeparovec-xioi) Open a PDF 9/16/2021
Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs PDF Open a PDF 9/16/2021
Humira ® (adalimumab) – for Psoriasis, Rheumatoid Arthritis, Juvenile Idiopathic Arthritis, Psoriatic Arthritis, Ankylosing Spondylitis, Hidradenitis Suppurativa, Crohn’s Disease, Ulcerative Colitis and Panuveitis Open a PDF 9/16/2021
Anorexiants; Contrave (naltrexone/bupropion ER), QsymiaTM (phentermine/topiramate ER), Saxenda (liraglutide), Wegovy (semaglutide) and Xenical® (orlistat), Imcivree (setmelanotide) Open a PDF 9/15/2021
Attention Deficit Hyperactivity Disorder (ADHD) Stimulants Policy Open a PDF 9/1/2021
Aduhelm (aducanumab-avwa) Policy Open a PDF 9/1/2021
Pulmonary Hypertension (PH) Open a PDF 9/1/2021
Alpha-1 Antitrypsin Therapy (AAT) Open a PDF 9/1/2021
Zulresso (brexanolone injection) for Postpartum Depression Open a PDF 7/15/2021
Generic Advantage Program / MAC Penalty Open a PDF 6/8/2021
Patient Protection and Affordable Care Act - Preventive Items and Services Open a PDF 6/22/2021
Off Label Use Open a PDF 5/6/2021
Hemlibra Open a PDF 5/6/2021
Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp) Open a PDF 5/6/2021
PDE-5 Inhibitor Drugs-Medical Necessity Review (MMC & HARP) Open a PDF 5/6/2021
Acthar Gel® (Repository Corticotropin Injection) - for Infantile Spasms, Multiple Sclerosis Exacerbations Open a PDF 5/6/2021
Osteoporosis - Evenity® (romosozumab-aqqg), Forteo® (teriparatide), Teriparatide, Prolia® (denosumab), Tymlos® (abaloparatide), Miacalcin injection®, calcitonin salmon injection Open a PDF 5/28/2021
Antihemophilic Agents Open a PDF 5/10/2021
Hereditary Angioedema (HAE) Open a PDF 3/9/2021
Sickle Cell Disease Management Policy Open a PDF 2/11/2021
Showing 1– 25 of 55 Results
IE Browser Modal