Pharmacy Policies
These administrative policies apply to our Georgia plans on the Health Insurance Marketplace.
Administrative policies offer guidance on determination of medical necessity, investigational and experimental services.
Some administrative policies conjoin with our pharmacy policies (such as non-formulary medications, off-label use, drug professional administration, etc.). Click below to review CareSource’s administrative policies:
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
Current Pharmacy Policies
A
- Abecma (idecabtagene vicleucel)
- Actemra (tocilizumab)
- Acthar Gel (repository corticotropin injection)
- Adakveo (crizanlizumab-tmca)
- Adalimumab (Amjevita, Humira)
- Adbry (tralokinumab-ldrm)
- Aduhelm (aducanumab-avwa)
- Aimovig (erenumab-aooe)
- Ajovy (fremanezumab-vfrm)
- Aldurazyme (laronidase)
- Amondys 45 (casimersen)
- Amvuttra (vutrisiran)
- Apretude (cabotegravir extended-release)
- Aralast NP, Glassia, Prolastin C, Zemaira (alpha1- proteinase inhibitor [human])
- Aranesp
- Arcalyst (Rilonacept)
- Aubagio (teriflunomide)
- Austedo (deutetrabenazine)
B
- Bafiertam (monomethyl fumarate)
- Benlysta (belimumab)
- Beovu (brolucizumab)
- Berinert (C1 esterase inhibitor (human))
- Bethkis (tobramycin inhalation solution)
- Bevacizumab (Alymsys, Avastin, Mvasi, Zirabev)
- Bleeding Disorder Agents
- Botox (onabotulinumtoxinA)
- Breyanzi (lisocabtagene maraleucel)
- Brineura (cerliponase alfa)
- Briumvi (ublituximab-xiiy)
- Bronchitol (mannitol)
- Bylvay (odevixibat)
C
- Cabenuva (cabotegravir/rilpivirine)
- Cablivi (caplacizumab-yhdp)
- Camzyos (mavacamten)
- Carbaglu (carglumic acid)
- Carvykti (ciltacabtagene autoleucel)
- Cayston (aztreonam inhalation solution)
- Cerdelga (eliglustat)
- Cibinqo (abrocitinib)
- Cimzia (certolizumab pegol)
- Cinqair (reslizumab)
- Cinryze (C1 esterase inhibitor (human))
- Continuous Glucose Monitors, Long Term
- Cortrophin Gel (corticotropin)
- Cosentyx (secukinumab)
- COVID-19 Vaccination
- Crysvita (burosumab-twza)
- Cuvrior (trientine tetrahydrochloride)
- Cytogam (cytomegalovirus immune globulin)
D
E
- Egrifta SV (tesamorelin)
- Elaprase (idursulfase)
- Emflaza (deflazacort)
- Emgality (galcanezumab-gnlm)
- Empaveli (pegcetacoplan)
- Enbrel (etanercept)
- Endothelin Receptor Antagonists for Pulmonary Arterial Hypertension: Letairis (ambrisentan), Opsumit (macitentan), Tracleer (bosentan)
- Enjaymo (sutimlimab)
- Enspryng (satralizumab-mwge)
- Entyvio (vedolizumab)
- ENZYME REPLACEMENT THERAPY (ERT) FOR GAUCHER DISEASE: Cerezyme (imiglucerase), Elelyso (taliglucerase alfa), Vpriv (velaglucerase alfa)
- Epclusa (Sofosbuvir/velpatasvir)
- Epidiolex (cannabidiol)
- Epoetin alfa (Epogen, Procrit, Retacrit)
- Esbriet (pirfenidone)
- Evenity (romosozumab-aqqg)
- Evkeeza (evinacumab-dgnb)
- Evrysdi (risdiplam)
- Exondys 51 (eteplirsen)
- Eylea (aflibercept)
F
G
H
I
- Ilaris (canakinumab)
- Ilumya (tildrakizumab-asmn)
- Iluvien (fluocinolone acetonide)
- Imbruvica
- Imcivree (setmelanotide)
- Immune globulin (IVIG and SCIG)
- Increlex (mecasermin)
- Infliximab (Avsola, Inflectra, Remicade, Renflexis)
- Ingrezza (valbenazine)
- Inhaled Prostacyclins for Pulmonary Arterial Hypertension: Tyvaso (treprostinil), Ventavis (iloprost)
- Injectable Prostacyclins for Pulmonary Arterial Hypertension: Flolan/Veletri (epoprostenol), Remodulin (treprostinil), Uptravi (selexipag)
- Interferons for Multiple Sclerosis: Avonex (interferon beta-1a), Betaseron (interferon beta-1b), Extavia (interferon beta-1b), Plegridy (peginterferon beta-1a), Rebif (interferon beta-1a)
- Intravenous Iron Products
- Isturisa (osilodrostat)
J
K
- Kalbitor (ecallantide)
- Kalydeco (ivacaftor)
- Kanuma (sebelipase alfa)
- Kesimpta (ofatumumab)
- Kevzara (sarilumab)
- Kineret (anakinra)
- Kitabis Pak (tobramycin inhalation solution)
- Korlym (mifepristone)
- Korsuva (difelikefalin)
- Koselugo (selumetinib)
- Krystexxa (pegloticase)
- Kuvan
- Kymriah (tisagenlecleucel)
L
M
- MACI (autologous cultured chondrocytes)
- Macrilen
- Macugen (pegaptanib)
- Mavenclad (cladribine)
- Mavyret (glecaprevir and pibrentasvir)
- Mayzent
- Medical Benefit Medications
- Mepsevii (vestronidase alfa-vjbk)
- Mircera (methoxy polyethylene glycol-epoetin beta)
- Mulpleta (lusutrombopag)
- Multi-ingredient Compound Policy
- Myalept (metreleptin)
- Mycapssa (octreotide)
- Myfembree (relugolix, estradiol, and norethindrone acetate)
- Myobloc (rimabotulinumtoxinB)
N
O
- Ocrevus (ocrelizumab)
- Ofev (nintedanib)
- Off Label Medication Requests
- Olumiant (baricitinib)
- Oncology Treatment Regimen Review
- Onpattro (patisiran)
- Oral Prostacyclins for Pulmonary Arterial Hypertension: Orenitram (treprostinil extended-release), Uptravi (selexipag tablets)
- Orencia (abatacept)
- Orfadin (nitisinone) Preferred Options: Nitisinone 2mg, 5mg, 10mg capsules, Orfadin 20mg capsules, Orfadin 4mg/mL suspension
- Oriahnn (elagolix, estradiol, and norethindrone acetate; elagolix)
- Orilissa (elagolix)
- Orkambi
- Orladeyo (berotralstat)
- Otezla (apremilast)
- Oxbryta (voxelotor)
- Oxervate (cenegermin-bkbj)
- Oxlumo
- Ozurdex (dexamethasone)
P
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp]
- Palynziq
- Panhematin (hemin for injection)
- Pegasys (peginterferon alfa-2a)
- Pegfilgrastim (Fulphila, Neulasta, Nyvepria, Udenyca, Ziextenzo)
- Personal Continuous Glucose Monitors
- Phosphodiesterase Type 5 Inhibitors (PDE-5 Inhibitors) for Pulmonary Arterial Hypertension: Adcirca/Alyq (tadalafil), Revatio (sildenafil)
- Ponvory
- Praluent (alirocumab)
- Prevymis (letermovir)
- Procysbi and Cystagon (cysteamine bitartrate); Cystaran and Cystadrops (cysteamine hydrochloride solution)
- Prolia (denosumab)
- Promacta (eltrombopag)
- Pulmozyme (dornase alfa inhalation solution)
- Pyrukynd (mitapivat)
Q
R
- Radicava
- Ravicti (glycerol phenylbuytyrate)
- Reblozyl
- Rebyota (fecal microbiota, live - jslm)
- Recorlev (levoketoconazole)
- Relistor (methylnaltrexone)
- Repatha (evolocumab)
- Retisert (fluocinolone acetonide)
- Revcovi (elapegademase-lvlr)
- Rezurock (belumosudil)
- Rinvoq (upadacitinib)
- Rituximab (Rituxan*, Truxima, Ruxience, Riabni)
- Ruconest (C1 esterase inhibitor (recombinant))
- Rukobia (fostemsavir)
- Ruzurgi (amifampridine)
- Ryplazim (plasminogen, human-tvmh)
S
- Saphnelo (anifrolumab-fnia)
- Scenesse
- Serostim (somatropin)
- Short Term Continuous Glucose Monitoring (Professional CGM)
- Short-Acting Somatropin Injections for Growth Hormone Deficiency - Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Zomacton
- Signifor, Signifor LAR (pasireotide)
- Siliq (brodalumab)
- Simponi (golimumab)
- Simponi Aria (golimumab)
- Skyrizi (risankizumab-rzaa)
- Skytrofa (lonapegsomatropin)
- Sodium Phenylbutyrate (Buphenyl, Pheburane, Olpruva)
- Sogroya (somapacitan-beco)
- Soliris (eculizumab)
- Soluble Guanylate Cyclase (sGC) Stimulator for Pulmonary Arterial Hypertension: Adempas (riociguat)
- Somatostatin analogs (Injectable; First generation): Sandostatin (octreotide), Sandostatin LAR (octreotide), Somatuline Depot (lanreotide), Bynfezia Pen (octreotide)
- Somavert (pegvisomant)
- Sotyktu (deucravacitinib)
- Sovaldi (sofosbuvir)
- Spevigo (spesolimab-sbzo)
- Spinraza (nusinersen)
- Spravato (esketamine)
- Stelara (ustekinumab)
- Strensiq (asfotase alfa)
- Sublocade (buprenorphine extended-release) injection, for subcutaneous use
- Suboxone (buprenorphine and naloxone sublingual film), Zubsolv (buprenorphine and naloxone sublingual tablets)
- Subutex (buprenorphine)
- Sunlenca (lenacapavir)
- Supprelin LA (histrelin acetate)
- Susvimo (ranibizumab)
- Symdeko (tezacaftor/ivacaftor)
- Synagis (palivizumab)
T
- Takhzyro (lanadelumab-flyo)
- Taltz (ixekizumab)
- Tarpeyo (budesonide)
- Tavalisse (fostamatinib disodium hexahydrate)
- Tavneos (avacopan)
- Tecartus (Brexucabtagene Autoleucel)
- Tecfidera (dimethyl fumarate)
- Tegsedi (inotersen)
- Tepezza (teprotumumab-trbw)
- Tezspire (tezepelumab-eeko)
- Tobi, Tobi Podhaler (tobramycin inhalation solution)
- Trastuzumab (Herceptin, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera)
- Tremfya (guselkumab)
- Trikafta (elexacaftor, tezacaftor and ivacaftor tablets; ivacaftor tablets)
- Triptodur (triptorelin)
- Trogarzo (ibalizumab-uiyk)
- Tymlos (abaloparatide)
- Tysabri (natalizumab)
- Tzield (teplizumab-mzwv)
U
V
- Vabysmo (faricimab-svoa)
- Vigabatrin (generic for Sabril), Vigadrone
- Vijoice (alpelisib)
- Viltepso (viltolarsen)
- Vimizim (elosulfase alfa)
- Visudyne (verteporfin)
- Vosevi (sofosbuvir/velpatasvir/voxilaprevir)
- VOXZOGO (vosoritide)
- Vumerity (diroximel fumarate)
- Vyepti (eptinezumab-jjmr)
- Vyndaqel (tafamidis meglumine) and Vyndamax (tafamidis)
- Vyondys 53 (golodirsen)
- Vyvgart (efgartigimod alfa-fcab)
W
X
- Xeljanz/Xeljanz XR (tofacitinib)
- Xenazine (tetrabenazine)
- Xenleta (lefamulin)
- Xenpozyme (olipudase alfa-rpcp)
- Xeomin (incobotulinumtoxinA)
- Xermelo (telotristat ethyl)
- Xgeva (denosumab)
- Xipere (triamcinolone)
- Xolair (omalizumab)
- Xyrem (sodium oxybate) and Xywav (calcium, magnesium, potassium, and sodium oxybates)
Y
Z
- Zavesca (miglustat)
- Zepatier (grazoprevir/elbasvir)
- Zeposia (ozanimod)
- Zeposia (ozanimod) - Archived 04/17/23
- Zokinvy (lonafarnib)
- Zoladex (goserelin acetate)
- Zolgensma (onasemnogene abeparvovec-xioi)
- Zorbtive (somatropin)
- Ztalmy (ganaxolone)
- Zulresso (brexanolone)
- Zynteglo (betibeglogene autotemcel)