Pharmacy Policies
These pharmacy policies apply to Medicare Advantage plans and the MyCare Ohio (Medicare-Medicaid) plan.
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
A
- Abraxane (paclitaxel albumin-bound suspension, intravenous infusion – Celgene, generic)
- Acthar® Gel (repository corticotropin intramuscular and subcutaneous injection – Mallinckrodt)
- Adcetris® (brentuximab intravenous infusion – Seattle Genetics)
- Aduhelm® (aducanumab-avwa intravenous infusion – Biogen/Eisai)
- Aldurazyme® (laronidase intravenous infusion – Genzyme)
- Alimta (pemetrexed intravenous infusion – Eli Lilly, generics)
- Aranesp® (darbepoetin alfa intravenous or subcutaneous injection − Amgen)
- Atgam® (lymphocyte immune globulin, anti-thymocyte globulin [equine] intravenous infusion – Pfizer)
B
C
D
E
F
G
H
I
J
K
L
- Lenmeldy™ (atidarsagene autotemcel intravenous infusion − Orchard)
- Lumizyme® (alglucosidase intravenous infusion – Genzyme)
- Lunsumio™ (mosunetuzumab-axgb intravenous infusion – Genentech)
- Lupron Depot® (leuprolide acetate suspension for intramuscular injection – AbbVie)
- Lutathera® (lutetium Lu 177 dotatate intravenous infusion – Advanced Accelerator Applications USA)
- Lymphir™ (denileukin diftitox-cxdl intravenous infusion – Citius)
M
N
- Naglazyme® (galsulfase intravenous infusion – BioMarin)
- Nexviazyme® (avalglucosidase alfa-ngpt intravenous infusion – Genzyme)
- Niktimvo™ (axatilimab-csfr intravenous infusion − Incyte/Syndax)
- Nplate® (romiplostim subcutaneous injection – Amgen)
- Nulibry™ (fosdenopterin intravenous infusion – Origin Biosciences)
O
P
- Padcev® (enfortumab vedotin-ejfv intravenous infusion – Astellas and Seagen)
- Palonosetron intravenous infusion (generic only)
- Pedmark® (sodium thiosulfate intravenous infusion – Fennec)
- Pemfexy™ (pemetrexed intravenous infusion – Eagle)
- Pemrydi RTU™ (pemetrexed disodium intravenous infusion – Amneal/Zydus)
- PiaSky® (crovalimab-akkz intravenous infusion or subcutaneous injection – Genentech)
- Pluvicto™ (lutetium Lu 177 vipivotide tetraxetan intravenous infusion – Advanced Accelerator Applications/Novartis)
- Pombiliti® (cipaglucosidase alfa-atga intravenous infusion – Amicus)
- Posfrea™ (palonosetron intravenous infusion) – Avyxa)
- Provenge® (sipuleucel-T intravenous infusion – Dendreon)
- Purified Cortrophin™ Gel (repository corticotropin subcutaneous and intramuscular injection – ANI)
Q
R
S
- Sarclisa® (isatuximab-irfc intravenous infusion – Sanofi-Aventis)
- Signifor® LAR (pasireotide intramuscular injection – Recordati Rare Diseases)
- Simponi Aria® (golimumab intravenous infusion – Janssen)
- Spevigo® (spesolimab-sbzo intravenous infusion − Boehringer Ingelheim)
- Syfovre™ (pegcetacoplan intravitreal injection – Apellis)
T
U
V
Y
Z
Cell and Gene Therapy Outcomes Tracking Program
CareSource Ohio Dual Advantage (D-SNP) partners with Audaire Health to capture and assess clinical benefits of Cell and Gene therapies. For more information, please refer to the CareSource Audaire Health™ Cell and Gene Therapy (CGT) Outcomes Tracking Program – Frequently Asked Questions for Providers. You can also find information about the program on our Updates & Announcements page.