Pharmacy Policies
These administrative policies apply to our West Virginia plans on the Health Insurance Marketplace.
Administrative policies offer guidance on determination of medical necessity, investigation and experimental services.
Some administrative policies conjoin with our pharmacy policies (such as, non-formulary medications, off-label use, drug professional administration, etc.). Click below to review CareSource’s administrative policies for:
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
A
- Abecma (idecabtagene vicleucel)
- Actemra (tocilizumab)
- Acthar Gel
- Adakveo (crizanlizumab-tmca)
- Adalimumab (Amjevita, Humira)
- Adbry (tralokinumab-ldrm)
- Aduhelm (aducanumab-avwa)
- Aimovig (erenumab-aooe)
- Ajovy (fremanezumab-vfrm)
- Aldurazyme (laronidase)
- Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin C, Zemaira [human])
- Amondys 45 (casimersen)
- Ampyra
- Amvuttra (vutrisiran)
- Apretude (cabotegravir extended-release)
- Aranesp
- Arcalyst (Rilonacept)
- Aubagio
- Austedo (deutetrabenazine)
B
- Bafiertam
- Benlysta
- Beovu
- Berinert
- Bethkis (tobramycin inhalation solution)
- Bevacizumab (Alymsys, Avastin, Mvasi, Zirabev)
- Beyfortus (nirsevimab)
- Bleeding Disorder Agents
- Botox (onabotulinumtoxinA)
- Breyanzi
- Brineura (cerliponase alfa)
- Briumvi (ublituximab-xiiy)
- Bronchitol (mannitol)
- Bylvay (odevixibat)
C
- Cabenuva (cabotegravir/rilpivirine)
- Cablivi (caplacizumab-yhdp)
- Camzyos
- Carbaglu (carglumic acid)
- Carvykti (ciltacabtagene autoleucel)
- Cayston (aztreonam inhalation solution)
- Cerdelga (eliglustat)
- Cibinqo (abrocitinib)
- Cimzia (certolizumab pegol)
- Cinqair (reslizumab)
- Cinryze
- Continuous Monitors, Long Term (FreeStyle Libre, Dexcom, Guardian, Eversense)
- Cortrophin Gel (corticotropin)
- Cosentyx (secukinumab)
- COVID-19 Vaccination
- Crysvita (burosumab-twza)
- Cuvrior
- Cytogam (cytomegalovirus immune globulin)
D
- Daklinza (daclatasvir)
- Dalfampridine (generic for Ampyra)
- Daraprim (pyrimethamine)
- Darzalex Faspro (daratumumab and hyaluronidase-fihj)
- Daybue (trofinetide)
- Diacomit
- Dispense as Written (DAW) Policy
- Dojolvi (triheptanoin)
- Doptelet (avatrombopag)
- Dupixent
- Durysta (bimatoprost intracameral implant)
- Dysport (abobotulinumtoxinA)
E
- Egrifta SV (tesamorelin)
- Elaprase (idursulfase)
- 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)
- Entyvio
- Enzyme Replacement Therapy (ERT) for Gaucher Disease: Cerezyme (imiglucerase), Elelyso (taliglucerase alfa), Vpriv (velaglucerase alfa)
- Epclusa (Sofosbuvir/velpatasvir)
- Epidiolex (cannabidiol)
- Epoetin alfa (Epogen, Procrit, Retacrit)
- Esbriet (pirfenidone)
- Evenity (romosozumab-aqqg)
- Evkeeza (evinacumab-dgnb)
- Evrysdi
- Exondys 51 (eteplirsen)
- Eylea (aflibercept)
F
G
H
I
- Ilaris (canakinumab)
- Ilumya (tildrakizumab-asmn)
- Iluvien (fluocinolone acetonide)
- Imbruvica
- Imcivree
- Immune globulin (IVIG and SCIG)
- Immune globulin (IVIG and SCIG): Intravenous (IVIG): Asceniv, Bivigam, Carimune NF, Flebogamma DIF, Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Panzyga, Privigen Subcutaneous (SCIG): Cutaquig, Cuvitru, Hizentra, HyQvia, Xembify)
- Increlex (mecasermin)
- Infliximab (Avsola, Inflectra, Remicade, Renflexis)
- 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)
- Interferon for MS
- Intravenous Iron Products
- Isturisa (osilodrostat)
J
K
L
M
- MACI (autologous cultured chondrocytes)
- Macrilen
- Macugen (pegaptanib)
- Mavenclad
- Mavyret (glecaprevir and pibrentasvir)
- Mayzent
- Medical Benefit Medications
- Mepsevii (vestronidase alfa-vjbk)
- Mircera (methoxy polyethylene glycol-epoetin beta)
- Mulpleta (lusutrombopag)
- Multi-ingredient Compound Policy
- Myalept (metreleptin)
- Mycapssa (octreotide)
- Myfembree
- Myobloc (rimabotulinumtoxinB)
N
O
- Ocrevus
- Ofev (nintedanib)
- Off Label Medication Requests
- Olumiant (baricitinib)
- Oncology Treatment Regimen Review
- Onpattro (patisiran)
- Oral Prostacyclins for Pulmonary Arterial Hypertension: Orenitram (treprostinil extended-release), Uptravi (selexipag tablets)
- Orencia (abatacept)
- Orfadin (nitisinone) Preferred Options: Nitisinone 2mg, 5mg, 10mg capsules, Orfadin 20mg capsules, Orfadin 4mg/mL suspension
- Oriahnn (elagolix, estradiol, and norethindrone acetate; elagolix)
- Orilissa
- Orkambi
- Orladeyo
- Otezla (apremilast)
- Oxbryta (voxelotor)
- Oxervate (cenegermin-bkbj)
- Oxlumo
- Ozurdex (dexamethasone)
P
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder- dnfp]
- Palynziq
- Panhematin (hemin for injection)
- Pegasys
- Pegfilgrastim (Fulphila, Neulasta, Nyvepria, Udenyca, Ziextenzo)
- Phosphodiesterase Type 5 Inhibitors (PDE-5 Inhibitors) for Pulmonary Arterial Hypertension: Adcirca/Alyq/Tadliq (tadalafil), Liqrev/Revatio (sildenafil)
- Ponvory
- 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
- Ranibizumab (Lucentis, Byooviz, Cimerli)
- Ravicti (glycerol phenylbuytyrate)
- Reblozyl
- Rebyota (fecal microbiota, live - jslm)
- Recorlev (levoketoconazole)
- Relistor (methylnaltrexone)
- Repatha (evolocumab)
- Retisert (fluocinolone acetonide)
- Revcovi (elapegademase-lvlr)
- Rezurock (belumosudil)
- Rinvoq (upadacitinib)
- Rituximab (Rituxan*, Truxima, Ruxience, Riabni)
- Ruconest
- Rukobia (fostemsavir)
- Ruzurgi (amifampridine)
- Ryplazim (plasminogen, human-tvmh)
S
- Saphnelo
- Scenesse
- Serostim (somatropin)
- Short Term Continuous Glucose Monitoring (Professional CGM)
- 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)
- Skyclarys (omaveloxolone)
- Skyrizi
- Skytrofa (lonapegsomatropin)
- Sodium Phenylbutyrate (Buphenyl, Pheburane, Olpruva)
- Sogroya (somapacitan-beco)
- Soliris (eculizumab)
- Soluble Guanylate Cyclase Stimulatorfor Pulmonary Arterial Hypertension: Adempas (riociguat)
- 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
- Spravato (esketamine)
- Stelara
- Strensiq (asfotase alfa)
- Sublocade
- Suboxone and Zubsolv
- Subutex (buprenorphine)
- 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
- Tegsedi
- Tepezza (teprotumumab-trbw)
- Tezspire (tezepelumab-eeko)
- Tobi, Tobi Podhaler (tobramycin inhalation solution)
- Trastuzumab (Herceptin, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera)
- Tremfya (guselkumab)
- Trikafta (elexacaftor, tezacaftor and ivacaftor; ivacaftor)
- Triptodur (triptorelin)
- Trogarzo (ibalizumab-uiyk)
- Turalio (pexidartinib)
- Tymlos (abaloparatide)
- Tysabri
- Tzield (teplizumab-mzwv)
U
V
- Vabysmo (faricimab-svoa)
- Vigabatrin
- Vijoice
- Viltepso (viltolarsen)
- Vimizim (elosulfase alfa)
- Visudyne (verteporfin)
- Vosevi (sofosbuvir/velpatasvir/voxilaprevir)
- Vowst (fecal microbiota spores, live-brpk)
- VOXZOGO (vosoritide)
- Vumerity
- Vyepti (eptinezumab-jjmr)
- Vyndaqel and Vyndamax
- Vyondys 53 (golodirsen)
- Vyvgart (efgartigimod alfa-fcab)
W
X
- Xeljanz/Xeljanz XR (tofacitinib)
- Xenazine (tetrabenazine)
- Xenleta (lefamulin)
- Xenpozyme (olipudase alfa-rpcp)
- Xeomin (incobotulinumtoxinA)
- Xermelo (telotristat ethyl)
- Xgeva (denosumab)
- Xipere (triamcinolone)
- Xolair (omalizumab)
- Xyrem (sodium oxybate), Lumryz (sodium oxybate extended release) and Xywav (calcium, magnesium, potassium, and sodium oxybates)
Y
Z
- Zarxio (filgrastim-sndz)
- Zavesca (miglustat)
- Zepatier (grazoprevir/elbasvir)
- Zeposia (ozanimod)
- Zinplava (bezlotoxumab)
- Zokinvy (lonafarnib)
- Zoladex (goserelin acetate)
- Zolgensma
- Zorbtive (somatropin)
- Ztalmy (ganaxolone)
- Zulresso (brexanolone)
- Zulresso (brexanolone)
- Zynteglo (betibeglogene autotemcel)