Pharmacy Policies
These clinical and administrative policies apply to our CareSource North Carolina Co.® plan on the Health Insurance Marketplace.
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 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.
A
- Abecma (idecabtagene vicleucel)
- Acthar Gel (repository corticotropin injection)
- Adakveo
- Adalimumab (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry)
- Adbry (tralokinumab-ldrm)
- Aduhelm
- Adzynma
- Aflibercept (Eylea, Eylea HD, Pavblu)
- Agamree (vamorolone)
- Aimovig (erenumab-aooe)
- Ajovy (fremanezumab-vfrm)
- Aldurazyme
- Alpha1-Proteinase Inhibitor (Aralast NP, Glassia, Prolastin C, Zemaira [human])
- Alyftrek (vanzacaftor/tezacaftor/deutivacaftor)
- Amondys 45
- Amvuttra (vutrisiran)
- Apretude (cabotegravir extended-release)
- Aqneursa (levacetylleucine)
- Aranesp (darbepoetin alfa)
- Arcalyst (rilonacept)
- Attruby (acoramidis)
- Aubagio (teriflunomide)
- Aucatzyl (obecabtagene autoleucel)
- Austedo (deutetrabenazine)
B
- Bafiertam (monomethyl fumarate)
- Benlysta (belimumab)
- Beovu (brolucizumab)
- Beqvez (fidanacogene elaparvovec-dzkt)
- Berinert
- Bethkis (tobramycin inhalation solution)
- Bevacizumab
- Bimzelx (bimekizumab-bkzx)
- Botox (onabotulinumtoxinA)
- Breyanzi (lisocabtagene maraleucel)
- Brineura (cerliponase alfa)
- Briumvi (ublituximab-xiiy)
- Bronchitol (mannitol)
- Buprenorphine extended-release (Sublocade, Brixadi)
- Bylvay (odevixibat)
C
- Cabenuva
- Cablivi (caplacizumab-yhdp)
- Camzyos
- Carbaglu (carglumic acid)
- Carvykti (ciltacabtagene autoleucel)
- Casgevy
- Cayston (aztreonam inhalation solution)
- Cerdelga (eliglustat)
- Cibinqo (abrocitinib)
- Cimzia (certolizumab pegol)
- Cinqair (reslizumab)
- Cinryze
- Clinical Review of Formulary and NonFormulary Medications
- Cortrophin Gel (corticotropin)
- Cosentyx (secukinumab)
- COVID-19 Vaccination
- Crenessity (crinecerfont)
- Crysvita
- Cuvrior (trientine tetrahydrochloride)
- Cytogam
D
- Daraprim (pyrimethamine)
- Darzalex Faspro (daratumumab and hyaluronidase-fihj)
- Daxxify (DaxibotulinumtoxinA-lanm)
- Daybue (trofinetide)
- Diacomit (stiripentol)
- Dispense as Written (DAW) Policy
- Dojolvi (triheptanoin)
- Doptelet (avatrombopag)
- Dupixent (dupilumab)
- Duvyzat (givinostat)
- Dysport (abobotulinumtoxinA)
E
- Ebglyss (lebrikizumab-lbkz)
- Egrifta SV (tesamorelin)
- Elaprase
- 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)
- Enspryng (satralizumab-mwge)
- Entyvio (vedolizumab)
- Epidiolex (cannabidiol)
- Epoetin alfa (Epogen, Procrit, Retacrit)
- Esbriet (pirfenidone)
- Evenity (romosozumab-aqqg)
- Evkeeza (evinacumab-dgnb)
- Evrysdi
- Exondys 51
- Eylea and Eylea HD (aflibercept)
F
- Fabhalta (iptacopan)
- Fasenra (benralizumab)
- Fensolvi (leuprolide acetate)
- Filgrastim (Neupogen, Zarxio, Nivestym, Releuko, Nypozi) and TBO-filgrastim (Granix)
- Filspari (sparsentan)
- Filsuvez
- Fingolimod (Gilenya, Tascenso ODT)
- Fintepla (fenfluramine)
- Firazyr
- Firdapse (amifampridine)
- Forteo (teriparatide)
G
H
I
- Ilaris (canakinumab)
- Ilumya (tildrakizumab-asmn)
- Iluvien (fluocinolone acetonide)
- Imbruvica (ibrutinib)
- Imcivree (setmelanotide)
- Immune globulin (IVIG and SCIG): Intravenous (IVIG): Alyglo, Asceniv, Bivigam, Flebogamma DIF, Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Panzyga, Privigen, Yimmugo Subcutaneous (SCIG): Cutaquig, Cuvitru, Hizentra, HyQvia, Xembify
- Increlex (mecasermin)
- Infliximab (Avsola, Inflectra, Remicade, Renflexis, Zymfentra)
- 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)
- Iqirvo (elafibranor)
- Isturisa
- Izervay (avacincaptad pegol)
J
K
- Kalbitor
- Kalydeco (ivacaftor)
- Kanuma (sebelipase alfa)
- Kebilidi (eladocagene exuparvovec-tneq)
- Kesimpta (ofatumumab)
- Kevzara (sarilumab)
- Kineret (anakinra)
- Kisunla (donanemab)
- Kitabis Pak (tobramycin inhalation solution)
- Korlym
- Koselugo (selumetinib)
- Krystexxa (pegloticase)
- Kuvan (sapropterin)
- Kymriah (tisagenlecleucel)
L
- Lamzede (velmanase alfa-tycv)
- Lemtrada
- Lenmeldy (atidarsagene autotemcel)
- Leqembi (lecanemab)
- Leqselvi (deuruxolitinib)
- Leqvio (inclisiran)
- Litfulo (ritlecitinib)
- Livdelzi (seladelpar)
- Livmarli (maralixibat)
- Livtencity (maribavir)
- Lost, Stolen, Damaged, Vacation and School Supply of Medication
- Lumizyme (alglucosidase alfa)
- Lupkynis (voclosporin)
- Lupron Depot and Lupron Depot-PED (leuprolide acetate)
- Luxturna (voretigene neparvovec-rzyl)
- Luxturna (voretigene neparvovec-rzyl)
- Lyfgenia (lovotibeglogene autotemcel)
M
- MACI (autologous cultured chondrocytes)
- Mavenclad (cladribine)
- Mavyret (glecaprevir and pibrentasvir)
- Mayzent (siponimod)
- Medical Benefit Medications
- Mepsevii
- Miplyffa (arimoclomol)
- Mircera (methoxy polyethylene glycolepoetin beta)
- Mulpleta (lusutrombopag)
- Multi-ingredient Compound Policy
- Myalept (metreleptin)
- Mycapssa
- Myfembree (relugolix, estradiol, and norethindrone acetate)
- Myobloc (rimabotulinumtoxinB)
N
O
- Ocaliva (obeticholic acid)
- Ocrevus (ocrelizumab) and Ocrevus Zunovo (ocrelizumab and hyaluronidaseocsq)
- Ofev (nintedanib)
- Off Label Medication Requests
- Ogsiveo
- Ohtuvayre (ensifentrine)
- Olumiant (baricitinib)
- Omvoh (Mirikizumab Mrkz)
- Oncology Regimens
- Onpattro (patisiran)
- Opsynvi (macitentan and tadalafil)
- Oral Prostacyclins for Pulmonary Arterial Hypertension: Orenitram (treprostinil extended-release), Uptravi (selexipag tablets)
- Orencia (abatacept)
- Oriahnn (elagolix, estradiol, and norethindrone acetate; elagolix)
- Orilissa (elagolix)
- Orkambi (Lumacaftor:ivacaftor)
- Orladeyo
- Otezla (apremilast)
- Oxervate (cenegermin-bkbj)
- Oxlumo (lumasiran)
- Ozurdex (dexamethasone)
P
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp]
- Palynziq (pegvaliase-pqpz)
- Panhematin
- Pegasys
- Pegfilgrastim (Fulphila, Neulasta, Nyvepria, Udenyca, Ziextenzo, Stimufend, Fylentra)
- Phosphodiesterase Type 5 Inhibitors (PDE-5 Inhibitors) for Pulmonary Arterial Hypertension: Adcirca/Alyq/Tadliq (tadalafil), Liqrev/Revatio (sildenafil)
- PiaSky (crovalimab-akkz)
- 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
- Rebyota (fecal microbiota, live - jslm)
- Recorlev
- Relistor (methylnaltrexone)
- Repatha (evolocumab)
- Retisert (fluocinolone acetonide)
- Rezdiffra (resmetirom)
- Rezurock (belumosudil)
- Rinvoq, Rinvoq LQ (upadacitinib)
- Rituximab (Rituxan, Truxima, Ruxience, Riabni)
- Rivfloza (nedosiran)
- Roctavian (valoctocogene roxaparvovec)
- Ruconest
- Rukobia
- Ryplazim (plasminogen, human-tvmh)
- Rystiggo (rozanolixizumab-noli)
S
- Saphnelo
- Scenesse (afamelanotide)
- Serostim (somatropin)
- Short-Acting Somatropin Injections for Growth Hormone Deficiency (Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Zomacton)
- Signifor, Signifor LAR
- Siliq (brodalumab)
- Simponi (golimumab)
- Simponi Aria (golimumab)
- Single Dose Vial – Claims Modifiers
- Skyclarys (omaveloxolone)
- Skyrizi (risankizumab-rzaa)
- Skysona (elivaldogene autotemcel)
- Skytrofa (lonapegsomatropin)
- Sodium Phenylbutyrate (Buphenyl, Pheburane, Olpruva)
- Sofosbuvir/Velpatasvir (Epclusa)
- Sogroya (somapacitan-beco)
- Sohonos (palovarotene)
- Soliris (eculizumab)
- Somatostatin analogs (Injectable; First generation): Sandostatin (octreotide), Sandostatin LAR (octreotide), Somatuline Depot (lanreotide), Bynfezia Pen (octreotide)
- Somavert
- Sotyktu (deucravacitinib)
- Sovaldi
- Spevigo (spesolimab-sbzo)
- Spinraza
- Spravato (esketamine)
- Spravato (Esketamine)
- Stelara (ustekinumab)
- Strensiq
- Sucraid (sacrosidase)
- Sunlenca
- 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
- Tepezza (teprotumumab-trbw)
- Tezspire (tezepelumab-eeko)
- Tobi, Tobi Podhaler (Tobramycin Inhalation Solution)
- Tocilizumab (Actemra, Tyenne, Tofidence)
- Trastuzumab (Herceptin, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera)
- Tremfya (guselkumab)
- Trikafta (Elexacaftor, Tezacaftor And Ivacaftor; Ivacaftor)
- Triptodur (triptorelin)
- Trogarzo
- Tryngolza (Olezarsen)
- Turalio (pexidartinib)
- Tymlos (abaloparatide)
- Tysabri (natalizumab)
- Tzield (Teplizumab Mzwv)
U
V
- Vabysmo (faricimab-svoa)
- Vafseo (vadadustat)
- Velsipity (etrasimod)
- Veopoz (Pozelimab)
- Vigabatrin (Sabril, Vigadrone, Vigafyde, Vigpoder)
- Vijoice (alpelisib)
- Viltepso
- Vimizim
- Visudyne (verteporfin)
- Vosevi
- Vowst (fecal microbiota spores, live-brpk)
- Voxzogo (vosoritide)
- Voydeya (danicopan)
- Vumerity
- Vyepti (eptinezumab-jjmr)
- Vyjuvek (beremagene geperpavec-svdt)
- Vyndaqel (Tafamidis Meglumine) And Vyndamax (Tafamidis)
- Vyondys 53
- Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc)
W
X
- Xalkori (crizotinib)
- Xeljanz/Xeljanz XR (tofacitinib)
- Xenazine (tetrabenazine)
- Xenpozyme (olipudase alfa-rpcp)
- Xeomin (incobotulinumtoxinA)
- Xermelo (Telotristat Ethyl)
- Xgeva (denosumab)
- Xipere (triamcinolone)
- Xolair (omalizumab)
- Xolremdi (mavorixafor)
- Xyrem (sodium oxybate), Xywav (calcium, magnesium, potassium, and sodium oxybates), Lumryz (sodium oxybate extended release)