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.
Current Pharmacy Policies
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)
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 MyCare 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.