Pharmacy Policies
These pharmacy policies apply to our Wisconsin Marketplace plans.
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 (crizanlizumab-tmca)
- Adalimumab (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry)
- Adbry (tralokinumab-ldrm)
- Adzynma (ADAMTS13, recombinant-krhn)
- Aflibercept (Eylea, Eylea HD, Pavblu)
- Agamree (vamorolone)
- Aimovig (erenumab-aooe)
- Ajovy (fremanezumab-vfrm)
- Aldurazyme (laronidase)
- Alpha1-Proteinase Inhibitor (Aralast NP, Glassia, Prolastin C, Zemaira [human])
- Alyftrek (vanzacaftor/tezacaftor/deutivacaftor)
- Amondys 45 (casimersen)
- 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 (C1 esterase inhibitor (human))
- Bethkis (tobramycin inhalation solution)
- Bevacizumab (Alymsys, Avastin, Mvasi, Zirabev)
- 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 (cabotegravir/rilpivirine)
- Cablivi (caplacizumab-yhdp)
- Camzyos (mavacamten)
- Carbaglu (carglumic acid)
- Carvykti (ciltacabtagene autoleucel)
- Casgevy (exagamglogene autotemcel)
- Cayston (aztreonam inhalation solution)
- Cerdelga (eliglustat)
- Cibinqo (abrocitinib)
- Cimzia (certolizumab pegol)
- Cinqair (reslizumab)
- Cinryze (C1 esterase inhibitor (human))
- Clinical Review of Formulary and Non-Formulary Medications
- Cortrophin Gel (corticotropin)
- Cosentyx (secukinumab)
- Crenessity (crinecerfont)
- Crysvita (burosumab-twza)
- Cuvrior (trientine tetrahydrochloride)
- Cytogam (cytomegalovirus immune globulin)
D
- Dalfampridine (generic for Ampyra)
- 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 (idursulfase)
- 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)
- Enjaymo (sutimlimab)
- Enspryng (satralizumab-mwge)
- Enzyme Replacement Therapy (ERT) for Fabry Disease: Fabrazyme (agalsidase beta) and Elfabrio (pegunigalsidase alfa-iwxj)
- Epidiolex (cannabidiol)
- Epoetin alfa (Epogen, Procrit, Retacrit)
- Esbriet (pirfenidone)
- Evenity (romosozumab-aqqg)
- Evkeeza (evinacumab-dgnb)
- Evrysdi (risdiplam)
- Exondys 51 (eteplirsen)
- 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 (birch triterpenes)
- Fingolimod (Gilenya, Tascenso ODT)
- Fintepla (fenfluramine)
- Firazyr or Sajazir (icatibant)
- 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 (osilodrostat)
- Izervay (avacincaptad pegol)
J
K
- Kalbitor (ecallantide)
- Kalydeco (ivacaftor)
- Kanuma (sebelipase alfa)
- Kebilidi (eladocagene exuparvovec-tneq)
- Kesimpta (ofatumumab)
- Kevzara (sarilumab)
- Kineret (anakinra)
- Kisunla (donanemab)
- Kitabis Pak (tobramycin inhalation solution)
- Korlym (mifepristone)
- Koselugo (selumetinib)
- Krystexxa (pegloticase)
- Kuvan (sapropterin)
- Kymriah (tisagenlecleucel)
L
- Lamzede (velmanase alfa-tycv)
- Lemtrada (alemtuzumab)
- 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)
- Lyfgenia (lovotibeglogene autotemcel)
M
- MACI (autologous cultured chondrocytes)
- Mavenclad (cladribine)
- Mavyret (glecaprevir and pibrentasvir)
- Mayzent (siponimod)
- Medical Benefit Medications
- Mepsevii (vestronidase alfa-vjbk)
- Miplyffa (arimoclomol)
- Mircera (methoxy polyethylene glycol-epoetin beta)
- Mulpleta (lusutrombopag)
- Multi-Ingredient Compound Policy
- Multi-Source Brand Policy
- Myalept (metreleptin)
- Mycapssa (octreotide)
- Myfembree (relugolix, estradiol, and norethindrone acetate)
- Myobloc (rimabotulinumtoxinB)
N
- Naglazyme (galsulfase)
- Nemluvio (nemolizumab-ilto)
- Nexviazyme (avalglucosidase alfa-ngp)
- Ngenla (somatrogon-ghla)
- Niktimvo (axatilimab)
- Nitisinone (Orfadin and Nityr)
- Nocdurna (desmopressin acetate)
- Non-Formulary Medications
- Novantrone (mitoxantrone)
- NPlate (romiplostim)
- Nucala (mepolizumab)
- Nulibry (fosdenopterin)
O
- Ocaliva (obeticholic acid)
- Ocrevus (ocrelizumab) and Ocrevus Zunovo (ocrelizumab and hyaluronidase-ocsq)
- Ofev (nintedanib)
- Off Label Medication Requests
- Ogsiveo (nirogacestat)
- 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 (berotralstat)
- Otezla (apremilast)
- Oxervate (cenegermin-bkbj)
- Oxlumo (lumasiran)
- Ozurdex (dexamethasone)
P
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp]
- Palynziq (pegvaliase-pqpz)
- Panhematin (hemin for injection)
- Pegasys (peginterferon alfa-2a)
- 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 (luspatercept-aamt)
- Rebyota (fecal microbiota, live - jslm)
- Relistor (methylnaltrexone)
- Repatha (evolocumab)
- Retisert (fluocinolone acetonide)
- Revcovi (elapegademase-lvlr)
- Rezdiffra (resmetirom)
- Rezurock (belumosudil)
- Rinvoq, Rinvoq LQ (upadacitinib)
- Rituximab (Rituxan, Truxima, Ruxience, Riabni)
- Rivfloza (nedosiran)
- Roctavian (valoctocogene roxaparvovec)
- Ruconest (C1 esterase inhibitor (recombinant))
- Rukobia (fostemsavir)
- Ryplazim (plasminogen, human-tvmh)
- Rystiggo (rozanolixizumab-noli)
S
- Saphnelo (anifrolumab-fnia)
- Scenesse (afamelanotide)
- Serostim (somatropin)
- Short-Acting Somatropin Injections for Growth Hormone Deficiency (Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Zomacton)
- Signifor, Signifor LAR (pasireotide)
- 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 (pegvisomant)
- Sotyktu (deucravacitinib)
- Sovaldi (sofosbuvir)
- Spevigo (spesolimab-sbzo)
- Spinraza (nusinersen)
- Spravato (esketamine)
- Stelara (ustekinumab)
- Strensiq (asfotase alfa)
- Sunlenca (lenacapavir)
- 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 (dimethyl fumarate)
- 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)
- Triptodur (triptorelin)
- Trogarzo (ibalizumab-uiyk)
- 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 (viltolarsen)
- Vimizim (elosulfase alfa)
- Visudyne (verteporfin)
- Vosevi (sofosbuvir/velpatasvir/voxilaprevir)
- Vowst (fecal microbiota spores, live-brpk)
- Voxzogo (vosoritide)
- Voydeya (danicopan)
- Vumerity (diroximel fumarate)
- Vyepti (eptinezumab-jjmr)
- Vyjuvek (beremagene geperpavec-svdt)
- Vyndaqel (tafamidis meglumine) and Vyndamax (tafamidis)
- Vyondys 53 (golodirsen)
- 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)