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:

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 Ohio Unified Preferred Drug List. Prescribers can access the UPDL documents online through ODM’s website by viewing the UPDL and UPDL criteria.

  • 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:

    A

    • Actemra (tocilizumab) • Aimovig (erenumab-aooe) • Ajovy (fremanezumab-vfrm) • Ampyra (Dalfampridine) • Aranesp (darbepoetin alfa) • 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

    • Kalydeco (ivacaftor) • 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) • Orkambi (lumacaftor/ivacaftor) • Otezla (apremilast)

    P

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

    R

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

    S

    • Sabril (vigabatrin) • Saizen (somatropin) • Serostim (somatropin) • Siliq (brodalumab) • Simponi (golimumab) • Skyrizi (risankizumab-rzaa) • Sovaldi (sofosbuvir) • Sublocade (buprenorphine extended-release) injection, for subcutaneous use • Symdeko (tezacaftor/ivacaftor)

    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