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 (repository corticotropin injection)
- Adakveo (crizanlizumab-tmca)
- Aduhelm (aducanumab-avwa)
- Aimovig (erenumab-aooe)
- Ajovy (fremanezumab-vfrm)
- Aldurazyme (laronidase)
- Amevive (alefacept)
- Amondys 45 (casimersen)
- Aralast NP, Glassia, Prolastin C, Zemaira (alpha1- proteinase inhibitor [human])
- Aranesp (darbepoetin alfa)
- Arcalyst (Rilonacept)
- Aubagio (teriflunomide)
- Austedo (deutetrabenazine)
- Avonex (interferon beta-1a)
B
- Bafiertam (monomethyl fumarate)
- Benlysta (belimumab)
- Beovu (brolucizumab)
- Berinert (C1 esterase inhibitor (human))
- Betaseron (interferon beta-1b)
- Bethkis (tobramycin inhalation solution)
- Bleeding Disorder Agents
- Botox (onabotulinumtoxinA)
- Breyanzi (lisocabtagene maraleucel)
- Brineura (cerliponase alfa)
- Bunavail (buprenorphine and naloxone) buccal film
- Bylvay (odevixibat)
C
D
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)
- Enspryng (satralizumab-mwge)
- Entyvio (vedolizumab)
- 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)
- Euflexxa (sodium hyaluronate)
- Evenity (romosozumab-aqqg)
- Evkeeza (evinacumab-dgnb)
- Evkeeza (evinacumab-dgnb)
- Evrysdi (risdiplam)
- Exondys 51 (eteplirsen)
- Exondys 51 (eteplirsen)
- Extavia (interferon beta-1b)
- Eylea (aflibercept)
F
G
H
I
- Ilaris (canakinumab)
- Ilumya (tildrakizumab-asmn)
- Iluvien (fluocinolone acetonide)
- Imbruvica (ibrutinib)
- Imcivree (setmelanotide)
- Immune globulin (IVIG and SCIG)
- Increlex (mecasermin)
- Inflectra (infliximab-dyyb)
- 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)
- Injectable somatostatin analogs (First generation): Sandostatin (octreotide), Sandostatin LAR (octreotide), Somatuline depot (lanreotide)
- Injectable somatostatin analogs (First generation): Sandostatin (octreotide), Sandostatin LAR (octreotide), Somatuline depot (lanreotide), Bynfezia Pen (octreotide)
- Isturisa (osilodrostat)
J
K
- Kalbitor (ecallantide)
- Kalydeco (ivacaftor)
- Kanuma (sebelipase alfa)
- Kesimpta (ofatumumab)
- Kevzara (sarilumab)
- Kineret (anakinra)
- Kitabis Pak (tobramycin inhalation solution)
- Korlym (mifepristone)
- Korsuva (difelikefalin)
- Koselugo (selumetinib)
- Krystexxa (pegloticase)
- Kuvan (sapropterin)
- Kymriah (tisagenlecleucel)
L
- Lemtrada (alemtuzumab)
- Leukine (sargramostim)
- Livmarli (maralixibat)
- Lucentis (ranibizumab)
- Lumizyme (alglucosidase alfa)
- Lupaneta Pack (leuprolide acetate, norethindrone acetate)
- Lupkynis (voclosporin)
- Lupron Depot and Lupron Depot-PED (leuprolide acetate)
- Luxturna (voretigene neparvovec-rzyl) intraocular suspension for subretinal injection
M
- MACI (autologous cultured chondrocytes)
- Macrilen (macimorelin)
- Macugen (pegaptanib)
- Mavenclad (cladribine)
- Mavyret (glecaprevir and pibrentasvir)
- Mayzent (siponimod)
- Mepsevii (vestronidase alfa-vjbk)
- Monovisc (sodium hyaluronate)
- Mulpleta (lusutrombopag)
- Myalept (metreleptin)
- Mycapssa (octreotide)
- Myfembree (relugolix, estradiol, and norethindrone acetate)
- Myobloc (rimabotulinumtoxinB)
N
- Naglazyme (galsulfase)
- Neulasta (Pegfilgrastim), Neulasta Onpro (Pegfilgrastim on-body injector)
- Neupogen (Filgrastim)
- Nexviazyme (avalglucosidase alfa-ngp)
- Nivestym (filgrastim-aafi)
- Noctiva (desmopressin acetate) intranasal 0.83 mcg/0.1 mL and 1.66 mcg/0.1 mL
- Novantrone (mitoxantrone)
- NPlate (romiplostim)
- Nucala (mepolizumab)
- Nulibry (fosdenopterin)
O
- Ocrevus (ocrelizumab)
- Ofev (nintedanib)
- 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 (elagolix)
- Orkambi (lumacaftor/ivacaftor)
- Orladeyo (berotralstat)
- Orthovisc (sodium hyaluronate)
- Otezla (apremilast)
- Oxbryta (voxelotor)
- Oxervate (cenegermin-bkbj)
- Oxlumo (lumasiran)
- Ozurdex (dexamethasone)
P
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder- dnfp]
- Palynziq (pegvaliase-pqpz)
- Pegasys (peginterferon alfa-2a)
- Phosphodiesterase Type 5 Inhibitors (PDE-5 Inhibitors) for Pulmonary Arterial Hypertension: Adcirca/Alyq (tadalafil), Revatio (sildenafil)
- Plegridy (peginterferon beta-1a)
- Ponvory (ponesimod)
- Praluent (alirocumab)
- Probuphine (buprenorphine subdermal implant)
- Procrit (epoetin alfa)
- Procysbi and Cystagon (cysteamine bitartrate); Cystaran and Cystadrops (cysteamine hydrochloride solution)
- Prolia (denosumab)
- Promacta (eltrombopag)
- Pulmozyme (dornase alfa inhalation solution)
Q
R
- Radicava (edaravone injection)
- Ravicti (glycerol phenylbuytyrate)
- Rebif (interferon beta-1a)
- Reblozyl (luspatercept-aamt)
- Relistor (methylnaltrexone)
- Remicade (infliximab)
- Renflexis (infliximab-abda)
- Repatha (evolocumab)
- Retacrit (epoetin alfa-epbx)
- Retisert (fluocinolone acetonide)
- Rezurock (belumosudil)
- Rinvoq (upadacitinib)
- Rituxan (rituximab)
- Ruconest (C1 esterase inhibitor (recombinant))
- Rukobia (fostemsavir)
- Ruzurgi (amifampridine)
- Ryplazim (plasminogen, human-tvmh)
S
- Saphnelo (anifrolumab-fnia)
- Short-Acting Somatropin Injections for Growth Hormone Deficiency - Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Zomacton
- Simponi Aria (golimumab)
- Skyrizi (risankizumab-rzaa)
- Skytrofa (lonapegsomatropin)
- Sogroya (somapacitan-beco)
- Soliris (eculizumab)
- Soluble Guanylate Cyclase (sGC) Stimulator for Pulmonary Arterial Hypertension: Adempas (riociguat)
- Spinraza (nusinersen)
- Spravato (esketamine)
- Stelara (ustekinumab)
- Strensiq (asfotase alfa)
- Sublocade (buprenorphine extended-release) injection, for subcutaneous use
- Suboxone (buprenorphine and naloxone) sublingual film, for sublingual or buccal use
- Subutex (buprenorphine)
- Supartz FX (sodium hyaluronate)
- Supprelin LA (histrelin acetate)
- Susvimo (ranibizumab)
- Symdeko (tezacaftor/ivacaftor)
- Synagis (palivizumab)
- Synvisc-One (sodium hyaluronate)
T
- Takhzyro (lanadelumab-flyo)
- Taltz (ixekizumab)
- Tavalisse (fostamatinib disodium hexahydrate)
- Tecartus (Brexucabtagene Autoleucel)
- Tecfidera (dimethyl fumarate)
- Tegsedi (inotersen)
- Tepezza (teprotumumab-trbw)
- Tobi (tobramycin inhalation solution), Tobi Podhaler
- Tremfya (guselkumab)
- Trikafta (elexacaftor, tezacaftor and ivacaftor tablets; ivacaftor tablets)
- Triptodur (triptorelin)
- Trogarzo (ibalizumab-uiyk)
- Tysabri (natalizumab)
U
V
- Varubi (rolapitant)
- Vigabatrin (generic for Sabril), Vigadrone
- Viltepso (viltolarsen)
- Vimizim (elosulfase alfa)
- Visudyne (verteporfin)
- Vosevi (sofosbuvir/velpatasvir/voxilaprevir)
- Vumerity (diroximel fumarate)
- Vyepti (eptinezumab-jjmr)
- Vyndaqel (tafamidis meglumine) and Vyndamax (tafamidis)
- Vyondys 53 (golodirsen)