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 75 Results
Title Last Updated
Medicare Part D Formulary Level Cumulative Opioid and Opioid / Buprenorphine POS Edits Open a PDF 11/30/2023
Interleukin Antagonists for Asthma and Other Conditions - Medical Benefit (Nucala (mepolizumab), Cinqair (reslizumab), Fasenra (benralizumab), Dupixent (dupilumab), & Adbry (tralokinumab-ldrm)) Open a PDF 11/07/2024
Oncology CRPA (Rx Benefit) (Self-Administration) - (Abiraterone 500 mg tablet, Afinitor, Akeega, Alecensa, Alunbrig, Augtyro, Ayvakit, Balversa, Besremi, (NOTE: both Rx and Medical benefit drug), Bosulif, Braftovi, Brukinsa, Cabometyx, Calquence, Caprelsa, Cometriq, Copiktra, Cotellic, Dasatinib, Daurismo, Disperz, Erivedge, Erleada, Exkivity, Fotivda, Fruzaqla, Gavreto, Gilotrif, Hemady, Ibrance, Iclusig, Idhifa, Imbruvica, Inlyta, Inqovi, Inrebic, Iressa, Iwilfin, Jakafi, Jaypirca, Kisqali and Kisqali Femara Co-Pack, Koselugo, Krazati, Lazcluze, Lenvima, Lonsurf, Lorbrena, Lumakras, Lynparza tablets, Lytgobi, Mekinist, Mektovi, Nerlynx, Nexavar, Ninlaro, Nubeqa, Odomzo, Ogsiveo, Ojemda, Ojjaara, Onureg, Orgovyx, Orserdu, Pemazyre, Piqray, Pomalyst, Purixan, Qinlock, Retevmo, Revlimid, Rezlidhia Rezurock, 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 11/06/2024
Coronavirus (COVID-19) Impacted Drug Therapies (Lagevrio (molnupiravir), Paxlovid (nirmatrelvir/ritonavir)) Open a PDF 11/04/2024
Clinical Review Prior Authorization (CRPA) Rx Drug Policy Open a PDF 11/01/2024
Dual Special Needs Plan (D-SNP) 2024 Prior Authorization Policy Open a PDF 11/01/2024
Medicare Part D 2024 Prior Authorization Policy Open a PDF 11/01/2024
Medicare Part D 2024 Step Therapy Open a PDF 11/01/2024
Dual Special Needs Plan (D-SNP) 2024 Step Therapy Policy Open a PDF 11/01/2024
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 11/01/2024
Rare Diseases CRPA Policy (Medical and Rx Benefits) - (Actimmune (Medical & Rx), Adzynma (Medical), Aldurazyme (Medical), Arcalyst (Rx), Bylvay (Rx), Camzyos (Rx), Cuprimine and generic penicillamine capsules (Rx), Cuvrior (Rx), Daybue (Rx), Empaveli (Rx), Enjaymo (Medical), Enspryng (Rx or 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), Lanreotide Acetate Injection (Medical & 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), Ruzurgi (Rx), Ryplazim (Medical & Rx), Rystiggo (Medical), Sandostatin LAR (Rx & Medical), Scenesse (Medical), Signifor LAR (Medical), Signifor SC (Rx), Skyclarys (Rx), Skysona (Medical), Sohonos (Rx), Soliris (Medical), Somavert (Rx), Sylvant (Medical), Syprine, generic trientine capsules (Rx), Tarpeyo (Rx), Tavneos (Rx), Tepezza (Medical), Thiola, Thiola EC, and generic tiopronin (Rx), Tzield (Medical), Ultomiris (Medical), Uplizna (Medical), Veopoz (Medical), Vijoice (Rx), Voxzogo (Rx), Voydeya (Rx), Vyjuvek (Medical), Vyvgart (Medical), Vyvgart Hytrulo (Medical), Xolremdi (Rx), Zilbrysq (Rx), Zokinvy (Rx), Ztalmy (Rx), Zynteglo (Rx)) Open a PDF 11/01/2024
Clinical Review Prior Authorization (CRPA) Policy - Medical Benefit for (Medicaid Managed Care, HARP, Essential Plan & Dual Special Needs Plan) - (Briumvi (Medical), Cablivi (Rx & Medical), Ceprotin (Medical), Eylea (Medical), Eylea HD (Medical), Gonadotropin-releasing hormone (GnRH) Analogs, Hydroxyprogesterone Caproate Injection (Medical), Krystexxa (Medical), Lemtrada (Medical), Leqvio (Medical), NPlate (Medical), Ocrevus (Medical), Pemgarda (Medical), Ranibizumab (Medical), Rebyota (Medical), Saphnelo (Medical), Spravato (Medical), Tysabri (Medical), Vabysmo (Medical), Zilretta (Medical), & Zoladex (Medical)) Open a PDF 10/31/2024
Weight Management Policy - Contrave, Orlistat, Qsymia, Saxenda, Wegovy, Xenical, Zepbound Open a PDF 10/31/2024
Xolair (omalizumab) Drug Policy Open a PDF 10/30/2024
Step Therapy Drug Policy - Acyclovir 5% cream, Adapalene 0.1% (Lotion, Soln, Swab), Admelog, Adlarity, AirDuo Digihaler, AirDuo Respiclick, Alogliptin, Alogliptin/metformin, Alogliptin/pioglitazone, Alvesco, Amitiza, Amzeeq, Anzemet, Apidra, Armonair Digihaler, Aspart Insulin, Aczone 7.5%, Aubagio, Bafiertam, Belsomra, Blood Glucose Meters and Test Strips, Brexafemme, Budesonide/Formoterol, Caplyta, Clindagel 75 mL, Clindamycin 1% Gel 75 mL (Oceanside & Solaris), Dapagliflozin, Dapagliflozin/Metformin, Dapsone 7.5%, Dayvigo, Denavir 1% Cream, Dexilant, Dexlansoprazole DR, Differin 0.1% Lotion, Doryx, Doryx MPC, Doxycycline hyclate DR, Drizalma Sprinkle, Duaklir Pressair, Ecoza, Edarbi, Edarbyclor, Edluar, Emsam, Ertaczo, Estring, Eucrisa Ointment, Fanapt, Fiasp, Flovent Diskus and Flovent HFA, Fluticasone-Vilanterol, Fluticasone-salmeterol HFA, Forfivo XL 450mg, Fortamet, Gelnique, Glumetza, Ibsrela, Insulin Aspart, Invokamet, Invokamet XR, Invokana, Kazano, Latanoprost/PF, Latuda, Livalo, Lonhala Magnair 25 mcg Refill & Starter, Luliconazole, Luzu, Lyuzeh, Metformin ER (generics of Fortamet and Glumetza), Metformin HCl 625 mg, Motegrity, Naftifine, Naftin Gel, Nesina, Norgesic Forte, Noritate, Novolin 70-30, Novolin N, Novolin R, Novolog, Novolog Mix 70/30, Omeprazole/Sodium Bicarbonate Packets, Onzetra Spray, Orphenadrine/Aspirin/Caffeine, Orphengesic Forte, Oseni, Osphena, Oxistat Lotion, Oxytrol, Pancreaze, Penciclovir 1% Cream, Pertzye, Pheburane, Ponvory, Praluent, Prograf Granules, Pulmicort Flexhaler, Qtern, Quviviq, Rezvoglar, Relistor Tablet, Restasis 0.05%, Restasis Multidose 0.05%, Rexulti, Rhopressa, Rocklatan, Savaysa, Sancuso, Savaysa, Savella, Secuado, Segluromet, Sernivo Lotion, Spiriva, Steglatro, Symproic, Tafluprost, Thalitone, Tosymra, Tudorza Pressair, Ultravate Lotion, Venlafaxine ER Tablets, Verdeso, Vraylar, Vumerity, Vyzulta, Xadago, Xelpros, Xerese 5%-1% Cream, Xolegel, Yupelri, Zegerid Packets, Zembrace, Zerviate, Zilxi 1.5%, Zioptan, Zolmitriptan Nasal Spray, Zomig Nasal Spray, Zolpimist, Zovirax 5% cream, Zuplenz, Zyclara 2.5% Cream Pump, Zyclara 3.75% Cream, Zyclara 3.75% Cream Pump, Zypitamag) Open a PDF 10/21/2024
Medicare Part B Step Therapy Drug List Open a PDF 10/18/2024
Oncology CRPA - Medical Benefit (Health Professional Administered) – (Abecma, Abraxane, Adcetris, Adstiladrin, Amtagvi, 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, Posfrea, Poteligeo, Pralatrexate, Provenge, Romidepsin, Rybrevant, Rylaze, Rytelo, Sarclisa, Talvey, Tecartus, Tecvayli, Temsirolimus, Tivdak, Torisel, Treanda, Trodelvy, Vectibix, Vivimusta, Vyxeos, Xgeva, Yescarta, Yondelis, Zaltrap, Zepzelca, & Zynlonta) Open a PDF 10/18/2024
Quantity Limit Open a PDF 10/15/2024
Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp) Open a PDF 10/15/2024
Non-Formulary Medication Exception Review Policy Open a PDF 10/15/2024
Medicare Part D 2025 Prior Authorization Policy Open a PDF 10/15/2024
Dual Special Needs Plan (D-SNP) 2025 Step Therapy Policy Open a PDF 10/14/2024
Dual Special Needs Plan (D-SNP) 2025 Prior Authorization Policy Open a PDF 10/14/2024
Medicare Part D 2025 Step Therapy Policy Open a PDF 10/14/2024
Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs - Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs - (Actemra - tocilizumab (Medical or Rx), Bimzelx, Cibinqo - abrocitinib (Rx), Cosentyx - secukinumab (Rx), 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 10/10/2024
Showing 1– 25 of 75 Results

 

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