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)
- Adbry (tralokinumab-ldrm)
- Aduhelm (aducanumab-avwa)
- Aimovig (erenumab-aooe)
- Ajovy (fremanezumab-vfrm)
- Aldurazyme (laronidase)
- Amondys 45 (casimersen)
- Ampyra
- Apretude (cabotegravir extended-release)
- Aralast NP, Glassia, Prolastin C, Zemaira (alpha1- proteinase inhibitor [human])
- Aranesp (darbepoetin alfa)
- Arcalyst (Rilonacept)
- Aubagio
- Austedo (deutetrabenazine)
B
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
- Cosentyx (secukinumab)
- Crysvita (burosumab-twza)
- Cuvrior
- Cytogam (cytomegalovirus immune globulin)
D
E
- Egrifta SV (tesamorelin)
- Elaprase (idursulfase)
- Emflaza (deflazacort)
- Emgality
- 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)v
- Epclusa (Sofosbuvir/velpatasvir)
- Epidiolex (cannabidiol)
- Epogen (epoetin alfa)
- 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 (ibrutinib)
- Imcivree
- Immune globulin (IVIG and SCIG)
- Increlex (mecasermin)
- Infliximab (Avsola, Inflectra, Remicade, Renflexis)
- Ingrezza (valbenazine)
- Inhaled Prostacyclins for PAH
- Injectable Prostacyclins for Pulmonary Arterial Hypertension: Flolan/Veletri (epoprostenol), Remodulin (treprostinil), Uptravi (selexipag)
- Interferon for MS
- Isturisa (osilodrostat)
J
K
L
M
- MACI (autologous cultured chondrocytes)
- Macrilen (macimorelin)
- Macugen (pegaptanib)
- Makena (hydroxyprogesterone caproate)
- Mavenclad
- Mavyret (glecaprevir and pibrentasvir)
- Mayzent (siponimod)
- Mepsevii (vestronidase alfa-vjbk)
- Mulpleta (lusutrombopag)
- Myalept (metreleptin)
- Mycapssa (octreotide)
- Myfembree
- Myobloc (rimabotulinumtoxinB)
N
O
- Ocrevus
- Ofev (nintedanib)
- Olumiant
- Oncology Treatment Regimen Review
- Onpattro
- 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 (lumacaftor/ivacaftor)
- Orladeyo
- Otezla (apremilast)
- Oxbryta (voxelotor)
- Oxervate (cenegermin-bkbj)
- Oxlumo (lumasiran)
- Ozurdex (dexamethasone)
P
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder- dnfp]
- Palynziq (pegvaliase-pqpz)
- Pegasys
- Pegfilgrastim (Fulphila, Neulasta, Nyvepria, Udenyca, Ziextenzo)
- Personal Continuous Glucose Monitors
- Phosphodiesterase Type 5 Inhibitors (PDE-5 Inhibitors) for Pulmonary Arterial Hypertension: Adcirca/Alyq (tadalafil), Revatio (sildenafil)
- Ponvory (ponesimod)
- Praluent (alirocumab)
- Prevymis (letermovir)
- Procrit (epoetin alfa)
- 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)
- Ravicti (glycerol phenylbuytyrate)
- Reblozyl (luspatercept-aamt)
- Recorlev (levoketoconazole)
- Relistor (methylnaltrexone)
- Repatha (evolocumab)
- Retacrit (epoetin alfa-epbx)
- Retisert (fluocinolone acetonide)
- Rezurock (belumosudil)
- Rinvoq (upadacitinib)
- Rituximab
- Ruconest
- Rukobia (fostemsavir)
- Ruzurgi (amifampridine)
- Ryplazim (plasminogen, human-tvmh)
S
- Saphnelo
- Scenesse (Afamelanotide)
- 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)
- Skyrizi
- Skytrofa (lonapegsomatropin)
- Sogroya (somapacitan-beco)
- Soliris (eculizumab)
- Soluble Guanylate Cyclase (sGC) Stimulator for Pulmonary Arterial Hypertension: Adempas (riociguat)
- Somatostatin analogs (Injectable; First generation): Sandostatin (octreotide), Sandostatin LAR (octreotide), Somatuline Depot (lanreotide), Bynfezia Pen (octreotide)
- Somavert (pegvisomant)
- Sovaldi (sofosbuvir)
- Spinraza
- Spravato (esketamine)
- Stelara
- Strensiq (asfotase alfa)
- Sublocade
- Suboxone (buprenorphine and naloxone sublingual film), Zubsolv (buprenorphine and naloxone sublingual tablets)
- Suboxone and Zubsolv
- Subutex (buprenorphine)
- Supprelin LA (histrelin acetate)
- Susvimo (ranibizumab)
- Symdeko (tezacaftor/ivacaftor)
- Synagis
T
- Takhzyro
- 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 tablets; ivacaftor tablets)
- Triptodur (triptorelin)
- Trogarzo (ibalizumab-uiyk)
- Tymlos (abaloparatide)
- Tysabri