Pharmacy Policies

These pharmacy policies apply to our Ohio Medicaid plan.

The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.

Current Pharmacy Policies

CareSource Managed Policies

The following medications are managed under the Medical Benefit at CareSource or are medications not included in the Ohio Department of Medicaid’s current Unified Preferred Drug List. Therefore, these medications utilize criteria outlined within the following policies:

• List of CareSource managed drugs

  Navigate

  A

  • Alpha-1 Proteinase Inhibitors
  • Amevive (alefacept)
  • Antihemophilic Agents
  • Aranesp (darbepoetin alfa)
  • Austedo (deutetrabenazine)

  B

  • Benlysta (belimumab)
  • Berinert (C1 Esterase Inhibitor (Human))
  • Biologic and other Ophthalmologic Agents
  • Boniva (ibandronate) injection
  • Botox (onabotulinumtoxinA)
  • Brineura (cerliponase alfa)
  • Bunavail (buprenorphine and naloxone) buccal film

  C

  • Cinqair (reslizumab)
  • Cinryze (C1 esterase inhibitor (human))
  • Crysvita (burosumab-twza)

  D

  • Doptelet (avatrombopag)
  • Durolane (sodium hyaluronate)
  • Dysport (abobotulinumtoxinA)

  E

  • Emflaza (deflazacort)
  • Entyvio (vedolizumab)
  • Enzyme Replacement Therapy
  • Euflexxa (sodium hyaluronate)
  • Evenity (romosozumab-aqqg)
  • Exondys 51 (eteplirsen)

  F

  • Fasenra (benralizumab)
  • Firazyr (Icatibant)
  • Firdapse (amifampridine)
  • Forteo (teriparatide injection)
  • Fulphila (pegfilgrastim-jmdb)

  G

  • Galafold (migalastat)
  • Gel-One (sodium hyaluronate)
  • Gelsyn-3 (sodium hyaluronate)
  • GenVisc 850 (sodium hyaluronate)

  H

  • H.P. Acthar Gel (repository corticotropin injection)
  • Haegarda (C1 inhibitor (human))
  • Home Infusion Therapy
  • Hyalgan (sodium hyaluronate)
  • Hymovis (sodium hyaluronate)

  I

  • Idiopathic Pulmonary Fibrosis
  • Ilaris (canakinumab)
  • Ilumya (tildrakizumab-asmn)
  • Immune Globulin (IVIG)
  • Ingrezza (valbenazine)

  K

  • Kalbitor (Ecallantide)
  • Kalydeco (ivacaftor)
  • Kanuma (sebelipase alfa)
  • Kymriah (tisagenlecleucel)

  L

  • Lemtrada (alemtuzumab)
  • Lupron Depot and Lupron Depot-PED (leuprolide acetate)
  • Luxturna (voretigene neparvovec-rzyl) intraocular suspension for subretinal injection

  M

  • Macrilen (macimorelin)
  • Makena (hydroxyprogesterone caproate)
  • Mepsevii (vestronidase alfa-vjbk)
  • Monovisc (sodium hyaluronate)
  • Mulpleta (lusutrombopag)
  • Myobloc (rimabotulinumtoxinB)

  N

  • Neulasta (Pegfilgrastim), Neulasta Onpro (Pegfilgrastim on-body injector)
  • Noctiva (desmopressin acetate)
  • Novantrone (mitoxantrone)
  • NPlate (romiplostim)
  • Nucala (mepolizumab)

  O

  • Ocrevus (ocrelizumab)
  • Oncology Medications
  • Onpattro (patisiran)
  • Orilissa (elagolix)
  • Orkambi (lumacaftor/ivacaftor)
  • Orthovisc (sodium hyaluronate)

  P

  • Palynziq (pegvaliase-pqpz)
  • Probuphine (buprenorphine subdermal implant)
  • Prolia (denosumab)
  • Promacta (eltrombopag)
  • Pulmonary Arterial Hypertension
  • Pulmozyme (dornase alfa inhalation solution)

  Q

  • Qbrexza (glycopyrronium) cloth, 2.4%

  R

  • Radicava (edaravone injection)
  • Ravicti (glycerol phenylbuytyrate)
  • Remicade (infliximab)
  • Rituxan (rituximab)
  • Ruconest (C1 esterase inhibitor (rabbit-derived))

  S

  • Simponi Aria (golimumab)
  • Soliris (eculizumab)
  • Spinraza (nusinersen)
  • Spravato (esketamine)
  • Stelara (ustekinumab)
  • Strensiq (asfotase alfa)
  • Sublocade (buprenorphine extended-release) injection, for subcutaneous use
  • Suboxone (buprenorphine and naloxone) sublingual film, for sublingual or buccal use
  • Subutex (buprenorphine)
  • Supartz FX (sodium hyaluronate)
  • Symdeko (tezacaftor/ivacaftor)
  • Synagis (palivizumab)
  • Synvisc (sodium hyaluronate)
  • Synvisc-One (sodium hyaluronate)

  T

  • Takhzyro (lanadelumab-flyo)
  • Tavalisse (fostamatinib disodium hexahydrate)
  • Tegsedi (inotersen)
  • Tysabri (natalizumab)

  U

  • Ultomiris (ravulizumab-cwvz)

  V

  • Vyndaqel (tafamidis meglumine) and Vyndamax (tafamidis)

  X

  • Xeomin (incobotulinumtoxinA)
  • Xolair (omalizumab)

  Y

  • Yescarta (axicabtagene ciloleucel)

  Z

  • Zavesca (miglustat)
  • Zolgensma (onasemnogene abeparvovec-xioi)
  • Zubsolv (buprenorphine and naloxone) sublingual tablets for sublingual administration
  • Zulresso (brexanolone)

Ohio Department of Medicaid Unified Preferred Drug List

The following medications are managed under the Pharmacy Benefit, or Pharmacy and Medical Benefit both, at CareSource and are found within the Ohio Department of Medicaid’s current Unified Preferred Drug List. Therefore, these medications utilize criteria outlined within the NavigateOhio Unified Preferred Drug List:

• List of drugs with criteria outlined in the UPDL

  For a complete description of criteria correlated to the medications below, please view the Ohio Unified Preferred Drug List found here:

  • NavigateOhio Unified Preferred Drug List

  A

  • Actemra (tocilizumab) • Aimovig (erenumab-aooe) • Ajovy (fremanezumab-vfrm) • Ampyra (Dalfampridine) • Aubagio (teriflunomide) • Avonex (interferon beta-1a)

  B

  • Betaseron (interferon beta-1b) • Bethkis (tobramycin inhalation solution) • Biologic Cholesterol Agents

  C

  • Cayston (aztreonam inhalation solution) • Cimzia (certolizumab pegol) • Cosentyx (secukinumab)

  D

  • Daklinza (daclatasvir) • Dupixent (dupilumab)

  E

  • Emgality (galcanezumab-gnlm) • Enbrel (etanercept) • Epclusa (sofosbuvir/velpatasvir) • Epidiolex (cannabidiol) • Epogen (epoetin alfa) • Extavia (interferon beta-1b)

  G

  • Genotropin (somatropin) • Gilenya (fingolimod) • Granix (tbo-filgrastim)

  H

  • Harvoni (ledipasvir/sofosbuvir) • Humatrope (somatropin) • Humira (adalimumab)

  K

  • Kevzara (sarilumab) • Kineret (anakinra) • Kitabis Pak (tobramycin inhalation solution)

  L

  • Leukine (sargramostim)

  M

  • Mavenclad (cladribine) • Mavyret (glecaprevir and pibrentasvir) • Mayzent (siponimod)

  N

  • Neupogen (filgrastim) • Norditropin (somatropin) • Nutropin AQ (somatropin)

  O

  • Olumiant (baricitinib) • Omnitrope (somatropin) • Orencia (abatacept) • Otezla (apremilast)

  P

  • Pegasys (peginterferon alfa-2a) • Pegylated and Non-Pegylated Interferon • Plegridy (peginterferon beta-1a) • Procrit (epoetin alfa)

  R

  • Rebif (interferon beta-1a) • Relistor (methylnaltrexone)

  S

  • Sabril (vigabatrin) • Saizen (somatropin) • Serostim (somatropin) • Siliq (brodalumab) • Simponi (golimumab) • Skyrizi (risankizumab-rzaa) • Sovaldi (sofosbuvir)

  T

  • Taltz (ixekizumab) • Tecfidera (dimethyl fumarate) • Tobi (tobramycin inhalation solution) • Tremfya (guselkumab)

  V

  • Varubi (rolapitant) • Vosevi (sofosbuvir/velpatasvir/voxilaprevir)

  X

  • Xeljanz/Xeljanz XR (tofacitinib)

  Z

  • Zarxio (filgrastim-sndz) • Zepatier (grazoprevir/elbasvir) • Zomacton (somatropin)

Archived Pharmacy Policies