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 51– 64 of 64 Results
Title Last Updated
Compounded Drug Products Policy Open a PDF 02/08/2024
Clinical Review Prior Authorization Rx (CRPA) Open a PDF 04/01/2024
Clinical Review Prior Authorization (Medical Benefit) - (Briumvi (ublituximab-xiiy) (Medical), Cablivi (caplacizumab-yhdp) (Rx & Medical), Ceprotin (Protein C Concentrate, Human) (Medical), Eylea HD (aflibercept) (Medical), Fensolvi (leuprolide acetate), Hydroxyprogesterone Caproate Injection (Medical), Krystexxa - pegloticase (Medical), Lemtrada - alemtuzumab (Medical), Leqvio - inclisiran (Medical), Nplate - romiplostim (Medical), Ocrevus (ocrelizumab) (Medical), Rebyota - fecal microbiota,live-jslm (Medical), Saphnelo – anifrolumab-fnia (Medical), Spravato – esketamine nasal spray (Medical), Sunlenca (lenacapavir) (Rx & Medical), Supprelin LA (histrelin acetate) (Medical), Syfovre - pegcetacoplan injection (Medical), Triptodur (triptorelin), Trogarzo (ibalizumab-uiyk) (Medical), Trogarzo – ibalizumab-uiyk (Medical), Tysabri (natalizumab) (Medical), Vabysmo - faricimab-svoa (Medical), Zilretta – triamcinolone acetonide extended-release (Medical), Zoladex – goserelin implant (Medical), or any other medical agent) Open a PDF 04/17/2024
Cimzia (Certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis and Rheumatoid Arthritis Open a PDF 12/06/2023
Chronic Hepatitis C (Pegasys, Peg-Intron, ribavirin, Sovaldi, Harvoni, ledipasvir/sofosbuvir, Zepatier, Epclusa, sofosbuvir/velpatasvir, Vosevi, Mavyret) for Commercial, NYSOH Individual Market, NYSOH Employer Group Market Products, and Managed Medicaid products (Vosevi only) Open a PDF 12/06/2023
Chimeric Antigen Receptor T Cell (CAR-T) Therapy – (Medical Benefit) (Health Professional Administered) - (Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, & Yescarta) Open a PDF 04/05/2024
Botulinum Toxin (Botox, Daxxify, Dysport, Myobloc, Xeomin) – for Medicaid Managed Care (MMC), Health and Recovery Program (HARP), Child Health Plus (CHP), Essential Plan (EP), and Dual Eligible Special Needs Plan (D-SNP) - Medical Benefit Open a PDF 03/15/2024
Blood Modifiers - (Cosela, Fulphila, Fylnetra, Granix, Neupogen, Nivestym, Nyvepria, Releuko, Rolvedon, Stimufend, Ziextenzo) - Rx (Self Administration) & Medical Benefits (Health Professional Administered) Open a PDF 04/02/2024
Attention Deficit Hyperactivity Disorder (ADHD) Policy - Azstarys, dextroamphetamine/amphetamine ER capsule (generic Mydayis), Dyanavel XR, Mydayis and Xelstrym, Adzenys XR ODT (amphetamine ER ODT), Adzenys ER (and generic amphetamine ER suspension), Cotempla XR ODT (methylphenidate ER ODT), Dyanavel XR (amphetamine ER suspension), Quillichew ER (methylphenidate ER chewable tablets), Quillivant (methylphenidate ER suspension), Desoxyn and generic methamphetamine (Rx), Jornay PM (methylphenidate ER capsules), Qelbree (viloxazine ER capsules) Open a PDF 02/08/2024
Antihemophilic Agents for Medicaid Managed Care (MMC), Health and Recovery Program (HARP), and Dual Eligible Special Needs Plan (D-SNP) Open a PDF 03/15/2024
Anti-Amyloid Directed Therapies Policy (Aduhelm (aducanumab-avwa) & Leqembi (lecanemab-irmb)) Open a PDF 9/7/2023
Amyotrophic Lateral Sclerosis (ALS) Policy - (Exservan, Qalsody, Radicava and Radicava ORS, Relyvrio, Teglutik, & Tiglutik) - Medical & Rx Benefit Open a PDF 04/12/2024
Alpha-1 Antitrypsin Therapy (AAT) Open a PDF 05/11/2023
Adalimumab (Self-Administered - Rx benefit) (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], Idacio®/ adalimumab-aacf [adalimumab-aacf], Simlandi® (adalimumab-ryvk), Yuflyma® [adalimumab-aaty], Yusimry™ [adalimumab-aqvh]) Open a PDF 04/17/2024
Showing 51– 64 of 64 Results

 

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