Pharmacy Policies
These pharmacy policies apply to our Wisconsin Marketplace plans.
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
A
- Abecma (idecabtagene vicleucel)
- Acthar Gel (repository corticotropin injection)
- Adakveo (crizanlizumab-tmca)
- Adalimumab (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry)
- Adbry (tralokinumab-ldrm)
- Adempas (riociguat)
- Adzynma (ADAMTS13, 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)
- Apretude (cabotegravir extended-release)
- Aranesp (darbepoetin alfa)
- 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)
- Bimzelx (bimekizumab-bkzx)
- Bimzelx (bimekizumab-bkzx)
- 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)
- Crysvita (burosumab-twza)
- Cuvrior (trientine tetrahydrochloride)
- Cytogam (cytomegalovirus immune globulin)
D
- Daklinza (daclatasvir)
- Dalfampridine (generic for Ampyra)
- Daraprim (pyrimethamine)
- Darzalex Faspro (daratumumab and hyaluronidase-fihj)
- Daxxify (DaxibotulinumtoxinA-lanm)
- Daybue (trofinetide)
- Diacomit (stiripentol)
- Dojolvi (triheptanoin)
- Doptelet (avatrombopag)
- Dupixent (dupilumab)
- Durysta (bimatoprost intracameral implant)
- 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)
- Enzyme Replacement Therapy (ERT) for Fabry Disease: Fabrazyme (agalsidase beta) and Elfabrio (pegunigalsidase alfa-iwxj)
- Epclusa (Sofosbuvir/velpatasvir)
- 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)
- Fasenra (benralizumab)
- Fensolvi (leuprolide acetate)
- Filgrastim (Neupogen, Zarxio, Nivestym, Releuko, Nypozi) and TBO-filgrastim (Granix)
- Filspari (sparsentan)
- Filsuvez (birch triterpenes)
- Fingolimod (Gilenya, Tascenso ODT)
- Fintepla (fenfluramine)
- Firazyr or Sajazir (icatibant)
- Firdapse (amifampridine)
- 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, Yimmugo 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)
- Iqirvo (elafibranor)
- Isturisa (osilodrostat)
- IV Iron Products
- Izervay (avacincaptad pegol)
J
K
- Kalbitor (ecallantide)
- Kalydeco (ivacaftor)
- Kanuma (sebelipase alfa)
- Kesimpta (ofatumumab)
- Kevzara (sarilumab)
- Kineret (anakinra)
- Kisunla (donanemab)
- Kitabis Pak (tobramycin inhalation solution)
- Korlym (mifepristone)
- Korsuva (difelikefalin)
- Koselugo (selumetinib)
- Krystexxa (pegloticase)
- Kuvan (sapropterin)
- Kymriah (tisagenlecleucel)
L
- Lamzede (velmanase alfa-tycv)
- Lemtrada (alemtuzumab)
- Leqembi (lecanemab)
- Leqselvi (deuruxolitinib)
- Leqvio (inclisiran)
- Litfulo (ritlecitinib)
- Livmarli (maralixibat)
- Livtencity (maribavir)
- Lucentis (ranibizumab)
- Lumizyme (alglucosidase alfa)
- Lupkynis (voclosporin)
- Lupron Depot and Lupron Depot-PED (leuprolide acetate)
- Luxturna (voretigene neparvovec-rzyl)
- Lyfgenia (lovotibeglogene autotemcel)
M
- MACI (autologous cultured chondrocytes)
- Macrilen (macimorelin)
- Makena (hydroxyprogesterone caproate)
- Mavenclad (cladribine)
- Mavyret (glecaprevir and pibrentasvir)
- Mayzent (siponimod)
- 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)
- Ogsiveo (nirogacestat)
- Ohtuvayre (ensifentrine)
- Olumiant (baricitinib)
- Omvoh (mirikizumab-mrkz)
- Oncology Regimens
- Onpattro (patisiran)
- Opsynvi (macitentan and tadalafil)
- Oral Prostacyclins for Pulmonary Arterial Hypertension: Orenitram (treprostinil extended-release), Uptravi (selexipag tablets)
- Orencia (abatacept)
- Orfadin (nitisinone)
- Oriahnn (elagolix, estradiol, and norethindrone acetate; elagolix)
- Orilissa (elagolix)
- Orkambi (lumacaftor/ivacaftor)
- Orladeyo (berotralstat)
- Otezla (apremilast)
- Oxbryta (voxelotor)
- Oxervate (cenegermin-bkbj)
- Oxlumo (lumasiran)
- Ozurdex (dexamethasone)
P
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp]
- Palynziq (pegvaliase-pqpz)
- 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)
- PiaSky (crovalimab-akkz)
- Pombiliti (cipaglucosidase alfa-atga) and Opfolda (miglustat)
- Ponvory (ponesimod)
- 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 (edaravone injection); Radicava ORS (edaravone oral suspension)
- Ranibizumab (Lucentis, Byooviz, Cimerli)
- Ravicti (glycerol phenylbuytyrate)
- Reblozyl (luspatercept-aamt)
- Rebyota (fecal microbiota, live - jslm)
- Relistor (methylnaltrexone)
- Relyvrio (sodium phenylbutyrate/ taurursodiol)
- Remicade (infliximab)
- Repatha (evolocumab)
- Retacrit (epoetin alfa-epbx)
- Retisert (fluocinolone acetonide)
- Rezdiffra (resmetirom)
- Rezurock (belumosudil)
- Rinvoq, Rinvoq LQ (upadacitinib)
- Rituxan (rituximab)
- 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 (afamelanotide)
- Serostim (somatropin)
- 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)
- 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 (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)
- 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)
- Tocilizumab (Actemra, Tyenne, Tofidence)
- 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)
- Xenleta (lefamulin)
- Xenpozyme (olipudase alfa-rpcp)
- Xeomin (incobotulinumtoxinA)
- Xermelo (telotristat ethyl)
- Xgeva (denosumab)
- Xipere (triamcinolone)
- Xolair (omalizumab)
- Xolremdi (mavorixafor)
- 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)