Pharmacy Policies
These clinical and administrative policies apply to our CareSource North Carolina Co.® plan 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.
A
- Abecma
- Actemra
- Acthar Gel (repository corticotropin injection)
- Adakveo
- Adalimumab (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry)
- Adbry
- Adempas (riociguat)
- Aduhelm
- Adzynma
- Agamree (vamorolone)
- Aimovig (erenumab-aooe)
- Ajovy (fremanezumab-vfrm)
- Aldurazyme
- Alpha1-Proteinase Inhibitor (Aralast NP, Glassia, Prolastin C, Zemaira [human])
- Amevive
- Amondys 45
- Ampyra
- Amvuttra (vutrisiran)
- Apretude (cabotegravir extended-release)
- Aranesp (darbepoetin alfa)
- Arcalyst
- Aubagio
- Austedo (deutetrabenazine)
B
C
D
E
- Egrifta SV (tesamorelin)
- Elaprase
- 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)
- Enspryng (satralizumab-mwge)
- Entyvio (vedolizumab)
- Epclusa (Sofosbuvir/velpatasvir)
- Epidiolex
- Epoetin alfa (Epogen, Procrit, Retacrit)
- Esbriet
- Evenity (romosozumab-aqqg)
- Evkeeza (evinacumab-dgnb)
- Evrysdi
- Exondys 51
- Eylea and Eylea HD (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, 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
- Izervay (avacincaptad pegol)
J
K
L
- Lamzede (velmanase alfa-tycv)
- Lemtrada
- Lenmeldy (atidarsagene autotemcel)
- Leqembi (lecanemab)
- Leqvio (inclisiran)
- Leukine
- Litfulo (ritlecitinib)
- Livmarli (maralixibat)
- Livtencity (maribavir)
- Lumizyme (alglucosidase alfa)
- Lupkynis (voclosporin)
- Lupron Depot and Lupron Depot-PED (leuprolide acetate)
- Luxturna (voretigene neparvovec-rzyl)
- Lyfgenia (lovotibeglogene autotemcel)
M
N
O
- Ocaliva (obeticholic acid)
- Ocrevus
- Ofev
- Ogsiveo
- Olumiant (baricitinib)
- Omvoh (mirikizumab-mrkz)
- Onpattro (patisiran)
- Opsynvi (macitentan and tadalafil)
- Oral Prostacyclins for Pulmonary Arterial Hypertension: Orenitram (treprostinil extended-release), Uptravi (selexipag tablets)
- Orencia (abatacept)
- Oriahnn (elagolix, estradiol, and norethindrone acetate; elagolix)
- Orilissa (elagolix)
- Orkambi (lumacaftor/ivacaftor)
- Orladeyo
- Otezla (apremilast)
- Oxbryta
- Oxervate (cenegermin-bkbj)
- Oxlumo (lumasiran)
- Ozurdex (dexamethasone)
P
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp]
- Palynziq
- Palynziq (pegvaliase-pqpz)
- Panhematin
- Pegasys
- 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 (ponesimod)
- Praluent (alirocumab)
- Prevymis (letermovir)
- Probuphine
- Procrit
- Procysbi and Cystagon (cysteamine bitartrate); Cystaran and Cystadrops (cysteamine hydrochloride solution)
- Prolia (denosumab)
- Promacta (eltrombopag)
- Pulmozyme
- Pyrukynd (mitapivat)
Q
R
- Radicava (edaravone injection); Radicava ORS (edaravone oral suspension)
- Ranibizumab (Lucentis, Byooviz, Cimerli)
- Ravicti (glycerol phenylbuytyrate)
- Reblozyl
- Rebyota (fecal microbiota, live - jslm)
- Recorlev
- Relistor
- Remicade
- Repatha (evolocumab)
- Retacrit
- Retisert (fluocinolone acetonide)
- Revcovi (elapegademase-lvlr)
- Rezdiffra (resmetirom)
- Rezurock (belumosudil)
- Rinvoq (upadacitinib)
- Rituximab (Rituxan, Truxima, Ruxience, Riabni)
- Rivfloza (nedosiran)
- Roctavian (valoctocogene roxaparvovec)
- Ruconest
- Rukobia
- Ryplazim (plasminogen, human-tvmh)
- Rystiggo (rozanolixizumab-noli)
S
- Saphnelo
- Scenesse (Afamelanotide)
- Serostim (somatropin)
- Short-Acting Somatropin Injections for Growth Hormone Deficiency (Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Zomacton)
- Signifor, Signifor LAR
- Siliq (brodalumab)
- Simponi (golimumab)
- Simponi Aria
- Skyclarys (omaveloxolone)
- Skyrizi (risankizumab-rzaa)
- Skysona (elivaldogene autotemcel)
- Skytrofa (lonapegsomatropin)
- Sodium Phenylbutyrate(Buphenyl, Pheburane, Olpruva)
- Sogroya (somapacitan-beco)
- Sohonos (palovarotene)
- Soliris (eculizumab)
- Soluble Guanylate Cyclase Stimulator for Pulmonary Arterial Hypertension: Adempas (riociguat)
- Somatostatin Analogs
- Somavert
- Sotyktu (deucravacitinib)
- Sovaldi
- Spevigo (spesolimab-sbzo)
- Spinraza
- Spravato (esketamine)
- Stelara
- Strensiq
- Suboxone (buprenorphine and naloxone sublingual film), Zubsolv (buprenorphine and naloxone sublingual tablets)
- Subutex (buprenorphine)
- Sucraid (sacrosidase)
- Sunlenca
- Supprelin LA (histrelin acetate)
- Susvimo (ranibizumab)
- Syfovre (pegcetacoplan)
- Symdeko
- Synagis (palivizumab)
T
- Takhzyro (lanadelumab-flyo)
- Taltz (ixekizumab)
- Tarpeyo
- Tavalisse (fostamatinib disodium hexahydrate)
- Tavneos
- Tecartus
- Tecfidera
- Tegsedi
- Tepezza (teprotumumab-trbw)
- Tezspire (tezepelumab-eeko)
- Tobi
- Trastuzumab (Herceptin, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera)
- Tremfya (guselkumab)
- Trikafta (elexacaftor, tezacaftor and ivacaftor; ivacaftor)
- Triptodur (triptorelin)
- Trogarzo
- Turalio (pexidartinib)
- Tymlos (abaloparatide)
- Tysabri (natalizumab)
- Tzield (teplizumab-mzwv)
U
V
- Vabysmo (faricimab-svoa)
- Vafseo (vadadustat)
- Velsipity (etrasimod)
- Veopoz (Pozelimab)
- Vigabatrin
- Vijoice
- Viltepso
- Vimizim
- Visudyne (verteporfin)
- Vosevi
- Vowst (fecal microbiota spores, live-brpk)
- Voxzogo (vosoritide)
- Voydeya (danicopan)
- Vumerity
- Vyepti (eptinezumab-jjmr)
- Vyjuvek (beremagene geperpavec-svdt)
- Vyndaqel and Vyndamax
- Vyondys 53
- 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
- Xgeva
- Xipere (triamcinolone)
- Xolair (omalizumab)
- Xolremdi (mavorixafor)
- Xyrem (sodium oxybate), Lumryz (sodium oxybate extended release) and Xywav (calcium, magnesium, potassium, and sodium oxybates)