Pharmacy Policies
These clinical and administrative policies apply to our Georgia plans on the Health Insurance Marketplace.
Pharmacy policies offer guidance on determination of coverage of pharmaceutical products. The coverage criteria are consistent with FDA-approved prescribing information, treatment guidelines and literature. The policies listed on this page are not 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
- Abecma (idecabtagene vicleucel)
- Actemra (tocilizumab)
- Acthar Gel (repository corticotropin injection)
- Adakveo (crizanlizumab-tmca)
- Adalimumab (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry)
- Adempas (riociguat)
- Aduhelm (aducanumab-avwa)
- Adzynma (ADAMT S13, recombinant-krhn)
- Agamree (vamorolone)
- Aimovig (erenumab-aooe)
- Ajovy (fremanezumab-vfrm)
- Aldurazyme (laronidase)
- Alpha1-Proteinase Inhibitor (Aralast NP, Glassia, Prolastin C, Zemaira [human])
- Amondys 45 (casimersen)
- Amvuttra (vutrisiran)
- Apretude (cabotegravir extended-release)
- Aranesp
- Arcalyst (Rilonacept)
- Aubagio (teriflunomide)
- 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)
- Beyfortus (nirsevimab)
- Bleeding Disorder Agents
- 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))
- Cortrophin Gel (corticotropin)
- Cosentyx (secukinumab)
- COVID-19 Vaccination
- 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
- Dispense as Written (DAW) Policy
- Dojolvi (triheptanoin)
- Doptelet (avatrombopag)
- Dupixent (dupilumab)
- Duvyzat (givinostat)
- Dysport (abobotulinumtoxinA)
E
- 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)
- Entyvio (vedolizumab)
- Enzyme Replacement Therapy (ERT) for Fabry Disease: Fabrazyme (agalsidase beta) and Elfabrio (pegunigalsidase alfaiwxj)
- Epclusa (Sofosbuvir/velpatasvir)
- 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)
- Fabrazyme
- Fasenra (benralizumab)
- Fensolvi (leuprolide acetate)
- Fensolvi (leuprolide acetate)
- Filgrastim (Neupogen, Zarxio, Nivestym, Releuko)
- Filspari (sparsentan)
- Filsuvez (birch triterpenes)
- Fingolimod (Gilenya, Tascenso ODT)
- Fintepla (fenfluramine)
- Firazyr or Sajazir (icatibant)
- Firdapse
- 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 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)
- Isturisa (osilodrostat)
- Izervay (avacincaptad pegol)
J
K
L
- Lamzede (velmanase alfa-tycv)
- Lemtrada (alemtuzumab)
- Lenmeldy (atidarsagene autotemcel)
- Leqembi (lecanemab)
- Leqvio (inclisiran)
- Litfulo (ritlecitinib)
- Livmarli (maralixibat)
- Livtencity (maribavir)
- Lucentis (ranibizumab)
- Lumizyme (alglucosidase alfa)
- 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
- Medical Benefit Medications
- Mepsevii (vestronidase alfa-vjbk)
- Mircera (methoxy polyethylene glycol-epoetin beta)
- Mulpleta (lusutrombopag)
- Multi-ingredient Compound Policy
- Myalept (metreleptin)
- Mycapssa (octreotide)
- Myfembree (relugolix, estradiol, and norethindrone acetate)
- Myobloc (rimabotulinumtoxinB)
N
O
- Ocaliva (obeticholic acid)
- Ocrevus (ocrelizumab)
- Ofev (nintedanib)
- Off Label Medication Requests
- Ogsiveo (nirogacestat)
- Olumiant (baricitinib)
- Omvoh (mirikizumab-mrkz)
- Oncology Treatment Regimen Review
- Onpattro (patisiran)
- Opsynvi (macitentan and tadalafil)
- 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
- Orladeyo (berotralstat)
- Otezla (apremilast)
- Oxbryta (voxelotor)
- Oxervate (cenegermin-bkbj)
- Oxlumo (lumasiran)
- Ozurdex (dexamethasone)
P
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp]
- Palynziq
- 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)
- Pombiliti (cipaglucosidase alfa-atga) and Opfolda (miglustat)
- 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 (luspatercept-aamt)
- Rebyota (fecal microbiota, live - jslm)
- Recorlev (levoketoconazole)
- Relistor (methylnaltrexone)
- Repatha (evolocumab)
- Retisert (fluocinolone acetonide)
- Revcovi (elapegademase-lvlr)
- Rezdiffra (resmetirom)
- Rezurock (belumosudil)
- Rinvoq (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
- Short Acting Somatropin (Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Zomacton)
- Signifor, Signifor LAR (pasireotide)
- Siliq (brodalumab)
- Simponi (golimumab)
- Simponi Aria (golimumab)
- Skyclarys (omaveloxolone)
- Skyrizi (risankizumab-rzaa)
- Skytrofa (lonapegsomatropin)
- Sodium Phenylbutyrate (Buphenyl, Pheburane, Olpruva)
- Sogroya (somapacitan-beco)
- Sohonos (palovarotene)
- 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 (nusinersen)
- Spravato (esketamine)
- Stelara (ustekinumab)
- Strensiq (asfotase alfa)
- Suboxone (buprenorphine and naloxone sublingual film), Zubsolv (buprenorphine and naloxone sublingual tablets)
- 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 (dimethyl fumarate)
- Tegsedi (inotersen)
- 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 (natalizumab)
- Tzield (teplizumab-mzwv)
U
V
- Vabysmo (faricimab-svoa)
- Vafseo (vadadustat)
- Velsipity (etrasimod)
- Veopoz (Pozelimab)
- Vigabatrin (generic for Sabril), Vigadrone
- 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) and Xywav (calcium, magnesium, potassium, and sodium oxybates)
- Xyrem (sodium oxybate), Lumryz (sodium oxybate extended release) and Xywav (calcium, magnesium, potassium, and sodium oxybates)
Y
Z
- Zavesca (miglustat)
- Zepatier (grazoprevir/elbasvir)
- Zeposia (ozanimod)
- Zilbrysq (zilucoplan)
- Zinplava (bezlotoxumab)
- Zokinvy (lonafarnib)
- Zoladex (goserelin acetate)
- Zolgensma (onasemnogene abeparvovec-xioi)
- Zorbtive (somatropin)
- Ztalmy (ganaxolone)
- Zulresso (brexanolone)
- Zynteglo (betibeglogene autotemcel)