Pharmacy Policies
These clinical and administrative policies apply to our Çï¿ûapp 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 .
A
- Abecma
- Actemra
- Adakveo
- Adalimumab (Amjevita, Humira)
- Adbry
- 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 PAH
- Inhaled Prostacyclins for Pulmonary Arterial Hypertension: Tyvaso (treprostinil), Ventavis (iloprost)
- Injectable Prostacyclins for Pulmonary Arterial Hypertension: Flolan/Veletri (epoprostenol), Remodulin (treprostinil), Uptravi (selexipag)
- Isturisa
- IV Iron Products
- Izervay (avacincaptad pegol)
J
K
L
M
N
O
- Ocaliva (obeticholic acid)
- Ocrevus
- Ofev
- Off Label Medication Requests
- Ogsiveo
- Olumiant (baricitinib)
- Omvoh (mirikizumab-mrkz)
- Onpattro (patisiran)
- Oral Prostacyclins for Pulmonary Arterial Hypertension: Orenitram (treprostinil extended-release), Uptravi (selexipag tablets)
- Orencia (abatacept)
- Oriahnn
- Orilissa
- Orkambi (lumacaftor/ivacaftor)
- Orladeyo
- Otezla
- Oxbryta
- Oxervate
- Oxlumo
- Ozurdex (dexamethasone)
P
- Palforzia
- Palynziq
- Palynziq (pegvaliase-pqpz)
- Panhematin
- Pegasys
- Pegfilgrastim
- Phosphodiesterase Type 5 Inhibitors (PDE-5 Inhibitors) for Pulmonary Arterial Hypertension: Adcirca/Alyq/Tadliq (tadalafil), Liqrev/Revatio (sildenafil)
- Phosphodiesterase Type 5 Inhibitors for PAH
- 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
- Promacta (eltrombopag)
- Pulmozyme
- Pyrukynd
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
- Relyvrio (sodium phenylbutyrate/ taurursodiol)
- Remicade
- Repatha (evolocumab)
- Retacrit
- Retisert (fluocinolone acetonide)
- Revcovi (elapegademase-lvlr)
- Rezurock
- Rinvoq (upadacitinib)
- Rituximab (Rituxan, Truxima, Ruxience, Riabni)
- Rivfloza
- Roctavian (valoctocogene roxaparvovec)
- Ruconest
- Rukobia
- Ryplazim
- 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
- 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
- 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
- Trikafta (elexacaftor, tezacaftor and ivacaftor; ivacaftor)
- Triptodur
- Trogarzo
- Turalio (pexidartinib)
- Tymlos (abaloparatide)
- Tysabri (natalizumab)
- Tzield (teplizumab-mzwv)
U
V
- Vabysmo (faricimab-svoa)
- Velsipity (etrasimod)
- Veopoz (Pozelimab)
- Vigabatrin
- Vijoice
- Viltepso
- Vimizim
- Visudyne (verteporfin)
- Vosevi
- Vowst (fecal microbiota spores, live-brpk)
- Voxzogo (vosoritide)
- 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
- Xyrem (sodium oxybate), Lumryz (sodium oxybate extended release) and Xywav (calcium, magnesium, potassium, and sodium oxybates)