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 79 Results
Title Last Updated
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
Oncology CRPA (Self-Administration) (Abiraterone 500 mg tablet, Afinitor, Afinitor Disperz, Akeega, Alecensa, Alunbrig, Augtyro, Avmapki Fakzynja co-pack, Ayvakit, Balversa, Besremi, (NOTE: both Rx and Medical benefit drug), Bexarotene Capsules, Bosulif, Braftovi, Brukinsa, Cabometyx, Calquence, Caprelsa, Cometriq, Copiktra, Cotellic, Danziten, Dasatinib, Daurismo, Ensacove, Erivedge, Erleada, Erlotinib, Everolimus tablets or suspension), Exkivity, Fotivda, Fruzaqla, Gavreto, Gefitinib, Gilotrif, Gomekli, Hemady, Hernexeos, Ibrance, Ibtrozi, Iclusig, Idhifa, Imbruvica (tablets or suspension), Imkeldi suspension, Inqovi, Inluriyo, Inlyta, Inrebic, Iressa, Itovebi, Iwilfin, Jakafi, Jaypirca, Kisqali, Komzifti, Koselugo, Krazati, Lapatinib, Lazcluze, Lenvima, Lonsurf, Lorbrena, Lumakras, Lynparza tablets, Lytgobi, Mekinist, Mektovi, Mercaptopurine oral suspension, Modeyso, Nerlynx, Nexavar, Nilotinib, Nilotinib d-tartrate, Ninlaro, Nubeqa, Odomzo, Ogsiveo, Ojemda, Ojjaara, Onureg, Orgovyx, Orserdu, Pazopanib, Pemazyre, Phyrago, Piqray, Pomalyst, Purixan, Qinlock, Retevmo, Revuforj, Rezlidhia Rezurock, Romvimza, Rozlytrek, Rubraca, Rydapt, Scemblix, Soltamox, Sorafenib, 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) - Rx Benefit Open a PDF 01/15/2026
Oncology Clinical Review Prior Authorization (CRPA) Medical Drug Policy (Abraxane, Adcetris, Adstiladrin, Amtagvi, Anktiva, Arzerra, Asparlas, Avgemsi, Axtle, Beizray, Beleodaq, Belrapzo, Bendamustine HCL, Bendeka, Besponsa, Bilprevda, Bispecific T-Cell Engagers (BiTE), Bizengri, Blenrep, Blincyto, Bomyntra, Boruzu, Camcevi, Cinvanti, Colimvi, Cyramza, Danyelza, Darzalex., Darzalex Faspro, Datroway, Docivyx, Elahere, Elitek, Elrexfio, Elzonris, Empliciti, Emrelis, Enhertu, Epkinly, Erwinaze, Focinvez, Folotyn, Fosaprepitant, Fyarro, Gazyva, Hepzato Kit, Imdelltra, Infugem, Inlexzo, Istodax, Ivra, Jelmyto, Kadcyla, Kimmtrak, Kyprolis, Kyxata, Lartruvo, Leuprolide Acetate Depot, Lumoxiti, Lunsumio, Lutrate Depot, Lymphir, Lynozyfic, Margenza, Monjuvi, Mylotarg, Niktimvo, Omisirge, Oncaspar, Onivyde, Osenvelt, Paclitaxel protein-bound particles, Padcev, Pedmark, Pemfexy, Pemrydi, Phesgo, Polivy, Portrazza, Posfrea, Poteligeo, Pralatrexate, Provenge, Romidepsin, Rybrevant, Rybrevant Faspro, Rylaze, Rytelo, Sarclisa, Talvey, Tecelra, Tecvayli, Temsirolimus, Tepylute, Tivdak, Torisel, Treanda, Trodelvy, Vectibix, Vivimusta, Vyloy, Vyxeos, Wyost, Xgeva, Yondelis, Zaltrap, Zepzelca, Ziihera, Zusduri, & Zynlonta) (Health Professional Administered) - Medical Benefit Open a PDF 01/06/2026
Oncology Biosimilar Drug Policy - (Avastin (bevacizumab) and Alymsys (bevacizumab-maly), Herceptin (trastuzumab), Herceptin Hylecta (trastuzumab and hyaluronidase-oysk), Hercessi (trastuzumab-strf), Jobevne (bevacizumab-mwgd) Ogivri (trastuzumab-dkst), Ontruzant (trastuzumab-dttb), and Herzuma (trastuzumab-pkrb), Rituxan (rituximab), Rituxan Hycela (rituximab hyaluronidase), Riabni (rituximab-arrx) and Vegzelma (bevacizumab-adcd)) – Medical Benefit Open a PDF 01/09/2026
Ohtuvayre (ensifentrine) Policy for Commercial, Exchange, & SafetyNet - Rx Benefit; Medicare Advantage & DSNP - Medical Benefit Open a PDF 11/19/2025
Off-Label Use of FDA Approved Drugs Open a PDF 05/08/2025
Non-Formulary Medication Exception Review Policy Open a PDF 01/01/2026
Monoclonal Antibodies for the Treatment of Hemophilia – (Health Professional Administered) Medical Benefit & (Self-Administered) Rx Benefit - (Alhemo, Hemlibra, Hympavzi, Qfitlia) Open a PDF 11/19/2025
Medicare Part D Formulary Level Cumulative Opioid and Opioid / Buprenorphine POS Edits Open a PDF 03/11/2025
Medicare Part D 2026 Step Therapy Policy Open a PDF 01/02/2026
Medicare Part D 2026 Prior Authorization Policy Open a PDF 01/09/2026
Medicare Part B Step Therapy Drug List Open a PDF 01/07/2026
Lyfgenia (lovotibeglogene autotemcel) Drug Policy (Health Professional Administered) - Medical Benefit Open a PDF 01/01/2026
Low Clinical Impact for Rx Drugs Policy Open a PDF 01/23/2026
Lantidra (donislecel-jujn) Drug Policy for Commercial, Essential Plan, Medicaid Managed Care & Medicare (Health Professional Administered) - Medical Benefit Open a PDF 01/01/2026
Kebilidi (eladocagene exuparvovec-tneq) (Health Professional Administered) - Medical Benefit Open a PDF 11/19/2025
Intravenous Iron Replacement Products Policy - Medical Benefit Open a PDF 11/19/2025
Intravenous Immune Globulin (IVIG) & Sub-Cutaneous Immune Globulin (SCIG) Therapy (Alyglo, Asceniv, Bivigam, Cutaquig, Cuvitru, Flebogamma, Gammagard Liquid, Gammagard S/D powder, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, & Xembify) (Self-Administered) - Rx Benefit & (Health Professional Administered) - Medical Benefit Open a PDF 01/23/2026
Interleukin Antagonists for Asthma and Other Conditions - (Health Professional Administered) Medical Benefit & (Self-Administered) Rx Benefit - (Adbry, Bullous Pemphigoid, Cinqair, Dupixent, Ebglyss, Fasenra, Nemluvio, & Nucala) Open a PDF 01/23/2026
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 01/23/2026
Infertility Medications Policy Open a PDF 10/08/2025
Inborn Errors of Metabolism Policy (Rx & Medical Benefit) – (Attruby, Amvuttra, Brineura, Carbaglu and generic carglumic acid, Cerdelga, Cerezyme, Cholbam, Crysvita, Ctexli, Dojolvi, Elaprase, Elelyso, Elfabrio, Fabrazyme, Galafold, Givlaari, Harliku, 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 11/19/2025
Immune Thrombocytopenia (ITP) Drug Policy (Alvaiz, Doptelet and Doptelet Sprinkle, eltrombopag tablet and powder for suspension, Nplate, Promacta, Tavalisse, Wayrilz) (Self-Administered & Health Professional Administered) – Rx Benefit & Medical Benefit Open a PDF 01/01/2026
Immune Checkpoint Inhibitor (CPI) (Health Professional Administered) - (Bavencio, Imfinzi, Imjudo, Jemperli, Keytruda, Keytruda Qlex, Libtayo, Loqtorzi, Opdivo, Optivo, Opdualag, Qvantig, Tecentriq, Tecentriq Hybreza, Tevimbra, Unloxcyt, Yervoy, and Zynyz) - Medical Benefit Open a PDF 11/19/2025
Hereditary Angioedema (HAE) for Andembry, Berinert, Cinryze, Dawnzera, Ekterly, Firazyr, Icatibant Haegarda, Kalbitor, Orladeyo, Ruconest, Sajazir, and Takhzyro (Self-Administered & Health Professional Administered) – Rx Benefit & Medical Benefit Open a PDF 01/09/2025
Showing 26– 50 of 79 Results

 

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