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 26– 50 of 75 Results
Title Last Updated
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
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
Off-Label Use of FDA Approved Drugs 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
Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs - (Actemra (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 (Medical or Rx), Tofidence (Medical), Tyenne (Medical & Rx), Xeljanz and Xeljanz XR- tofacitinib and tofacitinib ER (Rx), Zeposia- ozanimod (Rx)) Open a PDF 05/08/2025
Casgevy (exagamglogene autotemcel) Drug Policy - Medical Benefit Open a PDF 05/08/2025
Antihemophilic Agents for Medicaid Managed Care (MMC), Health and Recovery Program (HARP), and Dual Eligible Special Needs Plan (D-SNP) Open a PDF 05/08/2025
Amyotrophic Lateral Sclerosis (ALS) Policy - (Qalsody, Radicava and Radicava ORS, Relyvrio, Teglutik & Tiglutik) - Medical & Rx Benefit Open a PDF 05/08/2025
Alpha-1 Antitrypsin Therapy (AAT) - Medical Benefit Open a PDF 05/08/2025
Adalimumab (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], adalimumab-aacf [adalimumab-aacf], Simlandi®/ adalimumab-ryvk (adalimumab-ryvk), Yuflyma®/adalimumab-aaty [adalimumab-aaty], Yusimry™ [adalimumab-aqvh] Open a PDF 05/08/2025
Ryoncil (remestemcel-l-rknd) Drug Policy - (Health Professional Administered) - Medical Benefit Open a PDF 05/08/2025
Diabetic Incretin Mimetic Agents Policy Open a PDF 05/01/2025
Geographic Atrophy Drug Policy (Health Professional Administered) - Medical Benefit (Izervay, Syfovre) Open a PDF 04/22/2025
Cimzia(certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis and Rheumatoid Arthritis (Self-Administered or Healthcare Professional Administered) - Rx Benefit or Medical Benefit Open a PDF 04/16/2025
Hemophilia Gene Therapies Policy - (Beqvez, Hemgenix & Roctavian) - Medical Benefit Open a PDF 04/01/2025
Step Therapy Drug Policy Open a PDF 03/13/2025
Medicare Part D Formulary Level Cumulative Opioid and Opioid / Buprenorphine POS Edits Open a PDF 03/11/2025
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), Xromi (Rx)) Open a PDF 03/10/2025
Showing 26– 50 of 75 Results

 

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