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
Zulresso (brexanolone injection) for Postpartum Depression Open a PDF 7/15/2021
Xolair (omalizumab) Open a PDF 11/2/2021
Viscosupplementation with Hyaluronic Acid Open a PDF 9/16/2021
Synagis® (Palivizumab): Respiratory Syncytial Virus (RSV) Prophylaxis Open a PDF 11/18/2021
Step Therapy Policy for Commercial Open, Select Self-Funded Commercial Closed, Child Health Plus, Essential Plan, Small Employer Group and Direct Pay Metal Plans Open a PDF 11/1/2021
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
Sickle Cell Disease Management Policy Open a PDF 2/11/2021
Remicade (infliximab), Renflexis (infliximab-adba), Avsola (infliximab-axxq) Open a PDF 12/3/2021
Rare Disease Clinical Review Prior Authorization (CRPA) Policy Open a PDF 11/12/2021
Quantity Limit Open a PDF 12/3/2021
Pulmonary Hypertension (PH) Open a PDF 9/1/2021
PDE-5 Inhibitor Drugs-Medical Necessity Review (MMC & HARP) Open a PDF 5/6/2021
PCSK9 Inhibitors Open a PDF 12/3/2021
Patient Protection and Affordable Care Act - Preventive Items and Services Open a PDF 6/22/2021
Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp) 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
Opioid Management Health & Safety Program Open a PDF 12/3/2021
Oncology Clinical Review Prior Authorization Rx Open a PDF 11/19/2021
Oncology Clinical Review Prior Authorization (CRPA) Medical Open a PDF 12/3/2021
Oncology Biosimilar Drug Policy Open a PDF 2/11/2021
Off Label Use Open a PDF 5/6/2021
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, Sprix, ketorolac/tromethamine nasal spray, Tivorbex, Vimovo, Vivlodex, meloxicam capsules, Zipsor, Zorvolex and diclofenac 35 mg capsules) Open a PDF 11/22/2021
Non-Formulary Medication Exception Review Policy for All Lines of Business Open a PDF 11/22/2021
Medicare D Formulary-Level Cumulative Opioid and Opioid / Buprenorphine POS Edits Open a PDF 11/25/2019
Showing 1– 25 of 55 Results
IE Browser Modal