Pharmacy Policies
These pharmacy policies apply to our Georgia Medicaid plan(s).
Pharmacy policies offer guidance on determination of coverage of pharmaceutical products. The coverage criteria are consistent with FDA – approved prescribing information, treatment guidelines and literature. The policies listed on this page are not all inclusive of all pharmaceutical products. New policies will be added as new pharmaceutical products become available or as needed. Existing policies are regularly reviewed and updated to reflect current treatment guidelines and prescribing information.
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 (Humira, Hadlima, Hyrimoz and Hulio)
- Adbry (tralokinumab-ldrm)
- Aduhelm (aducanumab-avwa)
- Agamree (vamorolone)
- Aimovig (erenumab-aooe)
- Ajovy (fremanezumab-vfrm)
- Aldurazyme (laronidase)
- Alpha1-Proteinase Inhibitor (Aralast NP, Glassia, Prolastin C, Zemaira [human])
- Amondys 45 (casimersen)
- Amvuttra (vutrisiran)
- Apretude (cabotegravir extended-release)
- Aranesp (darbepoetin alfa)
- 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)
- Beyfortus (nirsevimab)
- Bimzelx (bimekizumab-bkzx)
- 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))
- Cortrophin Gel (corticotropin)
- Cosentyx (secukinumab)
- COVID-19 Vaccination
- Crysvita (burosumab-twza)
- Cuvrior (trientine tetrahydrochloride)
- Cytogam (cytomegalovirus immune globulin)
D
- Daklinza (daclatasvir)
- Dalfampridine (generic for Ampyra)
- Daraprim (pyrimethamine)
- Darzalex Faspro (daratumumab and hyaluronidase-fihj)
- Daxxify (DaxibotulinumtoxinA-lanm)
- Daybue (trofinetide)
- Diacomit (stiripentol)
- Dojolvi (triheptanoin)
- Doptelet (avatrombopag)
- Dupixent (dupilumab)
- Durysta (bimatoprost intracameral implant)
- Dysport (abobotulinumtoxinA)
E
- Egrifta SV (tesamorelin)
- Elaprase (idursulfase)
- Elevidys (delandistrogene moxeparvovec-rokl)
- 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 Fabry Disease: Fabrazyme (agalsidase beta) and Elfabrio (pegunigalsidase alfa-iwxj)
- Epclusa (Sofosbuvir/velpatasvir)
- Epidiolex (cannabidiol)
- Epoetin alfa (Epogen, Procrit, Retacrit)
- Esbriet (pirfenidone)
- Evenity (romosozumab-aqqg)
- Evkeeza (evinacumab-dgnb)
- Evrysdi (risdiplam)
- Eylea and Eylea HD (aflibercept)
F
- Fabrazyme (agalsidase beta)
- Fasenra (benralizumab)
- Fensolvi (leuprolide acetate)
- Filgrastim (Neupogen, Zarxio, Nivestym, Releuko)
- Filspari (sparsentan)
- Fingolimod (Gilenya, Tascenso ODT)
- Fintepla (fenfluramine)
- Firazyr or Sajazir (icatibant)
- Firdapse (amifampridine)
- Firdapse (amifampridine)
- Forteo (teriparatide)
- Fulphila (pegfilgrastim-jmdb)
G
H
I
- Ilaris (canakinumab)
- Ilumya (tildrakizumab-asmn)
- Iluvien (fluocinolone acetonide)
- Imbruvica (ibrutinib)
- Imcivree (setmelanotide)
- Immune globulin (IVIG and SCIG): Intravenous (IVIG): Asceniv, Bivigam, Carimune NF, Flebogamma DIF, Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Panzyga, Privigen Subcutaneous (SCIG): Cutaquig, Cuvitru, Hizentra, HyQvia, Xembify)
- Increlex (mecasermin)
- Inflectra (infliximab-dyyb)
- Ingrezza (valbenazine)
- Inhaled Prostacyclins for Pulmonary Arterial Hypertension: T yvaso (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)
- Isturisa (osilodrostat)
- IV Iron Products
- Izervay (avacincaptad pegol)
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 (sapropterin)
- Kymriah (tisagenlecleucel)
L
- Lamzede (velmanase alfa-tycv)
- Lemtrada (alemtuzumab)
- Leqembi (lecanemab)
- Leqvio (inclisiran)
- Litfulo (ritlecitinib)
- Livmarli (maralixibat)
- Livtencity (maribavir)
- Lumizyme (alglucosidase alfa)
- Lupkynis (voclosporin)
- Lupron Depot and Lupron Depot-PED (leuprolide acetate)
- Luxturna (voretigene neparvovec-rzyl)
M
- MACI (autologous cultured chondrocytes)
- Macrilen (macimorelin)
- Macugen (pegaptanib)
- Mavenclad (cladribine)
- Mavyret
- Mayzent (siponimod)
- Medicaid Drug Rebate Program (MDRP) Coverage Rules - AC Reject
- Medical Necessity – Off Label
- Medical Necessity for DAW
- Medical Necessity for Non-Formulary Medications
- Mepsevii (vestronidase alfa-vjbk)
- Mircera (methoxy polyethylene glycolepoetin beta)
- Mulpleta (lusutrombopag)
- Multi-ingredient Compound Policy
- Myalept (metreleptin)
- Mycapssa (octreotide)
- Myfembree (relugolix, estradiol, and norethindrone acetate)
- Myobloc (rimabotulinumtoxinB)
N
- Naglazyme (galsulfase)
- Neulasta (Pegfilgrastim), Neulasta Onpro (Pegfilgrastim on-body injector)
- Nexviazyme (avalglucosidase alfa-ngp)
- Ngenla (somatrogon-ghla)
- Nitisinone (Orfadin and Nityr)
- Nocdurna (desmopressin acetate)
- Novantrone (mitoxantrone)
- NPlate (romiplostim)
- Nucala (mepolizumab)
- Nulibry (fosdenopterin)
O
- Ocaliva (obeticholic acid)
- Ocrevus (ocrelizumab)
- Ofev (nintedanib)
- Olumiant (baricitinib)
- Omvoh (mirikizumab-mrkz)
- Oncology Treatment Regimen Review
- Onpattro (patisiran)
- Oral Prostacyclins for Pulmonary Arterial Hypertension: Orenitram (treprostinil extended-release), Uptravi (selexipag tablets)
- Orencia (abatacept)
- Orencia (abatacept) - Archived on 04/01/2024
- Oriahnn (elagolix, estradiol, and norethindrone acetate; elagolix)
- Orilissa (elagolix)
- Orkambi (lumacaftor/ivacaftor)
- Orladeyo (berotralstat)
- Otezla (apremilast)
- Oxbryta (voxelotor)
- Oxervate (cenegermin-bkbj)
- Oxlumo (lumasiran)
- Ozurdex (dexamethasone)
P
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp]
- Palynziq (pegvaliase-pqpz)
- Panhematin (hemin for injection)
- Pegasys (peginterferon alfa-2a)
- Phosphodiesterase T ype 5 Inhibitors (PDE-5 Inhibitors) for Pulmonary Arterial Hypertension: Adcirca/Alyq/Tadliq (tadalafil), Liqrev/Revatio (sildenafil)
- Pombiliti (cipaglucosidase alfa-atga) and Opfolda (miglustat)
- Ponvory (ponesimod)
- 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 (edaravone injection); Radicava ORS (edaravone oral suspension)
- Ranibizumab (Lucentis, Byooviz, Cimerli)
- Ravicti (glycerol phenylbuytyrate)
- Reblozyl (luspatercept-aamt)
- Rebyota (fecal microbiota, live - jslm)
- Recorlev (levoketoconazole)
- Relistor (methylnaltrexone)
- Relyvrio (sodium phenylbutyrate/ taurursodiol)
- Remicade (infliximab)
- Renflexis (infliximab-abda)
- Repatha (evolocumab)
- Retisert (fluocinolone acetonide)
- Revcovi (elapegademase-lvlr)
- Rezurock (belumosudil)
- Rinvoq (upadacitinib)
- Rituxumab (Rituxan, Truxima, Ruxience, Riabni)
- Rivfloza (nedosiran)
- Roctavian (valoctocogene roxaparvovec)
- Ruconest (C1 esterase inhibitor (recombinant))
- Rukobia (fostemsavir)
- Ruzurgi (amifampridine)
- Ryplazim (plasminogen, human-tvmh)
- Rystiggo (rozanolixizumab-noli)
S
- Saphnelo (anifrolumab-fnia)
- Scenesse (Afamelanotide)
- Serostim (somatropin)
- 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)
- Skyclarys (omaveloxolone)
- Skyrizi (risankizumab-rzaa)
- Skysona (elivaldogene autotemcel)
- Skytrofa (lonapegsomatropin)
- Sodium Phenylbutyrate (Buphenyl, Pheburane, Olpruva)
- Sogroya (somapacitan-beco)
- Sohonos (palovarotene)
- Soliris (eculizumab)
- Soluble Guanylate Cyclase 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
- Spevigo (spesolimab-sbzo)
- Spinraza (nusinersen)
- Spravato (esketamine)
- Stelara (ustekinumab)
- Strensiq (asfotase alfa)
- Suboxone (buprenorphine and naloxone sublingual film), Zubsolv (buprenorphine and naloxone sublingual tablets)
- Subutex (buprenorphine)
- Sucraid (sacrosidase)
- Sunlenca (lenacapavir)
- Supprelin LA (histrelin acetate)
- Susvimo (ranibizumab)
- Syfovre (pegcetacoplan)
- 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)
- Tremfya (guselkumab)
- Trikafta (elexacaftor, tezacaftor and ivacaftor; ivacaftor)
- Triptodur (triptorelin)
- Trogarzo (ibalizumab-uiyk)
- Turalio (pexidartinib)
- Tymlos (abaloparatide)
- Tysabri (natalizumab)
- Tzield (teplizumab-mzwv)
U
V
- Vabysmo (faricimab-svoa)
- Velsipity (etrasimod)
- Veopoz (Pozelimab)
- Veopoz (Pozelimab)
- Vigabatrin (generic for Sabril), Vigadrone
- Viltepso (viltolarsen)
- Vimizim (elosulfase alfa)
- Visudyne (verteporfin)
- Vosevi
- Vowst (fecal microbiota spores, live-brpk)
- Voxzogo
- Vumerity (diroximel fumarate)
- Vyepti (eptinezumab-jjmr)
- Vyjuvek (beremagene geperpavec-svdt)
- Vyndaqel (tafamidis meglumine) and Vyndamax (tafamidis)
- Vyondys 53 (golodirsen)
- Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc)
W
X
- Xalkori (crizotinib)
- Xeljanz/Xeljanz XR (tofacitinib)
- Xenazine (tetrabenazine)
- Xenleta (lefamulin)
- Xenpozyme (olipudase alfa-rpcp)
- Xermelo (telotristat ethyl)
- Xgeva (denosumab)
- Xipere (triamcinolone)
- Xolair (omalizumab)
- Xyrem (sodium oxybate), Lumryz (sodium oxybate extended release) and Xywav (calcium, magnesium, potassium, and sodium oxybates)