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.

Make a Comment

We invite practitioners to review & comment on our policies.

Showing 51– 75 of 81 Results
Title Last Updated
Hereditary Angioedema (HAE) for Andembry, Berinert, Cinryze, Ekterly, Firazyr, Icatibant Haegarda, Kalbitor, Orladeyo, Ruconest, Sajazir, and Takhzyro Open a PDF 11/19/2025
Hepatitis-C Virus (HCV) Infection (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) (Self Administered) - Rx Benefit Open a PDF 11/13/2025
Hemophilia Gene Therapies Policy - (Hemgenix & Roctavian) - Medical Benefit Open a PDF 11/20/2025
Headache Disorder – (Aimovig (erenumab-aooe) (Rx), Ajovy (fremanezumab-vfrm) (Rx & Medical), dihydroergotamine 1 mg/mL ampule (Rx), Elyxyb (celecoxib oral solution) Rx, Emgality 120 mg (galcanezumab-gnlm) (Rx), Emgality 300 mg (galcanezumab-gnlm) (Rx), Ergomar (ergotamine tartrate) Rx, Migranal, dihydroergotamine 4 mg/mL nasal spray, Nurtec ODT (rimegepant) (Rx), Qulipta (atogepant) (Rx), Reyvow (lasmiditan) (Rx), Ubrelvy (ubrogepant) (Rx), Vyepti (eptinezumab-jjmr) (Medical), Zavzpret (zavegepant) (Rx) & Quantity Limit Criteria for Ubrelvy, Nurtec ODT, Reyvow, and Zavzpret) Open a PDF 11/19/2025
Growth Hormone Policy Open a PDF 10/13/2025
Geographic Atrophy Drug Policy (Health Professional Administered) - Medical Benefit (Izervay, Syfovre) Open a PDF 11/19/2025
Generic Advantage Program / MAC Penalty Open a PDF 02/20/2025
Gamma-Aminobutyric Acid (GABA) A Receptor Positive Modulators for Postpartum Depression (Self-Administered) - Rx Benefit Open a PDF 11/20/2025
Encelto (revakinagene taroretcel-lwey) Implant (Health Professional Administered) - Medical Benefit Open a PDF 11/19/2025
Enbrel (etanercept) – for Ankylosing Spondylitis, Juvenile Idiopathic Arthritis, Plaque Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis Open a PDF 11/13/2025
Elevidys (delandistrogene moxeparvovec-rokl) (Medicaid Managed Care, Essential Plan, Commercial, & Medicare) - Medical Benefit Open a PDF 11/19/2025
Duchenne Muscular Dystrophy (DMD) - (Agamree, Amondys 45, Duvyzat, Emflaza, Exondys 51, Viltepso and Vyondys 53) (Self-Administered) - Rx Benefit & (Health Professional Administered) - Medical Benefit Open a PDF 11/20/2025
Dual Special Needs Plan (D-SNP) 2026 Step Therapy Policy Open a PDF 10/14/2025
Dual Special Needs Plan (D-SNP) 2026 Prior Authorization Policy Open a PDF 10/14/2025
Dual Special Needs Plan (D-SNP) 2025 Step Therapy Policy Open a PDF 12/01/2025
Dual Special Needs Plan (D-SNP) 2025 Prior Authorization Policy Open a PDF 12/01/2025
Diabetic Incretin Mimetic Agents Policy Open a PDF 11/13/2025
Compounded Drug Products Policy Open a PDF 02/06/2025
Clinical Review Prior Authorization (CRPA) Rx Drug Policy Open a PDF 11/13/2025
Clinical Review Prior Authorization (CRPA) Policy (Health Professional Administered) for (Medicaid Managed Care, HARP, Essential Plan & Dual Special Needs Plan) - (Benlysta IV, Briumvi, Cablivi (Rx & Medical), Ceprotin, Eylea, Eylea HD, Fensolvi, Gazyva, Gonadotropin-releasing hormone (GnRH) Analogs, Hydroxyprogesterone Caproate Injection, Krystexxa, Lemtrada, Leqvio, NPlate, Ocrevus, Ocrevus Zunovo , Pavblo, Pemgarda, Ranibizumab, Rebyota, Saphnelo, Spravato, Supprelin LA, Triptodur, Tyruko, Tysabri, Vabysmo, Zilretta, & Zoladex) – Medical Benefit Open a PDF 12/01/2025
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 11/19/2025
Chimeric Antigen Receptor T Cell (CAR-T) Therapy – (Health Professional Administered) (Abecma, Aucatzyl, Breyanzi, Carvykti, Kymriah, Tecartus, & Yescarta) - Medical Benefit Open a PDF 12/05/2025
Casgevy (exagamglogene autotemcel) Drug Policy (Health Professional Administered) - Medical Benefit Open a PDF 11/19/2025
Botulinum Toxin (Botox, Daxxify, Dysport, Myobloc, Xeomin) – for Medicaid Managed Care (MMC), Health and Recovery Program (HARP), Child Health Plus (CHP), Essential Plan (EP), Exchange Plans, Commercial, and Dual Eligible Special Needs Plan (D-SNP) - Medical Benefit Open a PDF 11/19/2025
Blood Modifiers - (Cosela, Fulphila, Fylnetra, Granix, Neupogen, Nivestym, Nypozi, Nyvepria, Releuko, Rolvedon, Ryzneuta, Stimufend, Ziextenzo) - Rx (Self Administration) & Medical Benefits (Health Professional Administered) Open a PDF 11/19/2025
Showing 51– 75 of 81 Results

 

GDPR Notification Content