Pharmacy Policies
These pharmacy policies apply to our CareSource PASSE™ plan.
Pharmacy policies offer guidance on determination of medical necessity coverage of pharmaceutical products. The coverage criteria are consistent with United States Food and Drug Administration (FDA)-approved prescribing information, treatment guidelines and literature. The policies listed on this page are not all-inclusive of all pharmaceutical products. New policies will be added as new pharmaceutical products become available or as needed. Existing policies are regularly reviewed and updated to reflect current treatment guidelines and prescribing information.
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
Current Pharmacy Policies
A
B
C
D
E
- Egrifta SV (tesamorelin)
- Elaprase (idursulfase)
- Elevidys (delandistrogene moxeparvovec-rokl)
- Enjaymo (sutimlimab)
- Enspryng (satralizumab-mwge)
- Entyvio (vedolizumab)
- Enzyme Replacement Therapy (ERT) for Fabry Disease: Fabrazyme (agalsidase beta) and Elfabrio (pegunigalsidase alfa-iwxj)
- ENZYME REPLACEMENT THERAPY (ERT) FOR GAUCHER DISEASE: Cerezyme (imiglucerase), Elelyso (taliglucerase alfa), Vpriv (velaglucerase alfa)
- Epidiolex (cannabidiol)
- Esbriet (pirfenidone)
- Euflexxa (sodium hyaluronate)
- Evkeeza (evinacumab-dgnb)
- Exondys 51 (eteplirsen)
- Eylea and Eylea HD (aflibercept)
F
G
H
I
J
K
L
M
- MACI (autologous cultured chondrocytes)
- Medicaid Drug Rebate Program (MDRP) Coverage Rules - AC Reject
- Medical Necessity - Off Label
- Medical Necessity for DAW
- Medical Necessity for Non-Formulary Medications
- Mepsevii (vestronidase alfa-vjbk)
- Multi-ingredient Compound Policy
- Myalept (metreleptin)
- Mycapssa (octreotide)
- Myobloc (rimabotulinumtoxinB)
N
O
P
Q
R
- Ranibizumab (Lucentis, Byooviz, Cimerli)
- Ravicti (glycerol phenylbuytyrate)
- Reblozyl (luspatercept-aamt)
- Rebyota (fecal microbiota, live - jslm)
- Retisert (fluocinolone acetonide)
- Rituximab (Rituxan, Truxima, Ruxience, Riabni)
- Roctavian (valoctocogene roxaparvovec)
- Ruconest (C1 esterase inhibitor (recombinant))
- Rukobia (fostemsavir)
- Ryplazim (plasminogen, human-tvmh)
- Rystiggo (rozanolixizumab-noli)
S
- Saphnelo (anifrolumab-fnia)
- Scenesse (Afamelanotide)
- Signifor, Signifor LAR (pasireotide)
- Skysona (elivaldogene autotemcel)
- Soliris (eculizumab)
- Somavert (pegvisomant)
- Spevigo (spesolimab-sbzo)
- Spinraza (nusinersen)
- Spravato (esketamine)
- Strensiq (asfotase alfa)
- Susvimo (ranibizumab)
- Syfovre (pegcetacoplan)
- Symdeko (tezacaftor/ivacaftor)
- Synagis (palivizumab)