Utilization Management

Prior Authorization, Step Therapy, and Quantity Limit Policies for CareSource Marketplace Business

Not all medications will be covered on the formulary. Non-formulary medications are subject to the Medical Necessity for Non-Formulary Medications policy. Please consult the formulary to verify coverage.

Allergen Immunotherapy - Grass Pollen Sublingual Products PA Policy De-Identified	Policy
Allergen Immunotherapy - Odactra PA Policy De-Identified	Policy
Allergen Immunotherapy - Palforzia DQM Policy - Per Rx De-Identified	Policy
Allergen Immunotherapy - Palforzia PA Policy De-Identified	Policy
Allergen Immunotherapy - Ragwitek PA Policy De-Identified	Policy
Alpha-Adrenergic Blockers - Doxazosin DQM Policy - Per Rx De-Identified	Policy
Alpha-Adrenergic Blockers - Terazosin DQM Policy - Per Rx De-Identified	Policy
Alpha1-Proteinase Inhibitor Products PA Policy De-Identified	Policy
Alzheimer's Disease Step Therapy Policy De-Identified	Policy
Alzheimers - Namenda, Namenda XR Step Therapy Policy De-Identified	Policy
Amifampridine Products PA Policy De-Identified	Policy
Amyloidosis - Amvuttra PA Policy De-Identified	Policy
Amyloidosis - Onpattro PA Policy De-Identified	Policy
Amyloidosis - Tafamidis Products PA Policy De-Identified	Policy
Amyloidosis - Tegsedi PA Policy De-Identified	Policy
Angiotensin Receptor Blocker Preferred Step Therapy Policy De-Identified	Policy
Angiotensin Receptor Blocker Step Therapy Policy De-Identified	Policy
Anti-Influenza - Relenza DQM Policy - Per Rx De-Identified	Policy
Anti-Influenza - Xofluza DQM Policy - Per Rx De-Identified	Policy
Anti-Influenza DQM Policy - Per Days De-Identified	Policy
Antibiotics - Linezolid (Zyvox), Sivextro PA Policy De-Identified	Policy
Antibiotics - Synercid PA Policy De-Identified	Policy
Antibiotics - Vancomycin Capsules PA Policy De-Identified	Policy
Antibiotics - Xifaxan PA Policy De-Identified	Policy
Antibiotics (Inhaled) - Arikayce PA Policy De-Identified	Policy
Antibiotics (Inhaled) - Cayston PA Policy De-Identified	Policy
Antibiotics (Inhaled) - TOBI Podhaler PA Policy De-Identified	Policy
Antibiotics (Inhaled) - Tobramycin Inhalation Solution PA Policy De-Identified	Policy
Antibiotics (Inhaled) - Tobramycin Products PSM Policy De-Identified	Policy
Antibiotics (Injectable) PA Policy De-Identified	Policy
Anticoagulants - Dabigatran PA Policy De-Identified	Policy
Anticoagulants - Eliquis PA Policy De-Identified	Policy
Anticoagulants - Savaysa PA Policy De-Identified	Policy
Anticoagulants - Xarelto PA Policy De-Identified	Policy
Antidepressants - Bupropion DQM Policy - Per Rx De-Identified	Policy
Antidepressants - Bupropion Long-Acting Step Therapy Policy De-Identified	Policy
Antidepressants - Selective Serotonin Reuptake Inhibitors DQM Policy - Per Rx De-Identified	Policy
Antidepressants - Selective Serotonin Reuptake Inhibitors Step Therapy Policy De-Identified	Policy
Antidepressants - Serotonin and Norepinephrine Reuptake Inhibitors DQM Policy - Per Rx De-Identified	Policy
Antidepressants - Serotonin and Norepinephrine Reuptake Inhibitors Step Therapy Policy De-Identified	Policy
Antiemetics - Doxylamine and Pyridoxine Combination Products DQM Policy - Per Days De-Identified	Policy
Antiemetics - Serotonin Receptor Antagonists (Oral and Transdermal) DQM Policy - Per Rx De-Identified	Policy
Antiemetics - Substance P-Neurokinin-1 Receptor Antagonists (Oral) DQM Policy - Per Rx De-Identified	Policy
Antiepileptics - Banzel PA Policy De-Identified	Policy
Antiepileptics - Clobazam Products PA Policy De-Identified	Policy
Antiepileptics - Depakote, Depakene Step Therapy Policy De-Identified	Policy
Antiepileptics - Diacomit PA Policy De-Identified	Policy
Antiepileptics - Epidiolex PA Policy De-Identified	Policy
Antiepileptics - Fintepla PA Policy De-Identified	Policy
Antiepileptics - Lacosamide Step Therapy Policy De-Identified	Policy
Antiepileptics - Lamictal XR Step Therapy Policy De-Identified	Policy
Antiepileptics - Levetiracetam, Brivaracetam Step Therapy Policy De-Identified	Policy
Antiepileptics - Nayzilam PA Policy De-Identified	Policy
Antiepileptics - Oxtellar XR, Trileptal Step Therapy Policy De-Identified	Policy
Antiepileptics - Valtoco PA Policy De-Identified	Policy
Antiepileptics - Vigabatrin PA Policy De-Identified	Policy
Antiepileptics - Zonisamide Step Therapy Policy De-Identified	Policy
Antiepileptics - Ztalmy PA Policy De-Identified	Policy
Antifungals - Cresemba (Oral) PA Policy De-Identified	Policy
Antifungals - Fluconazole (Oral) DQM Policy - Per Rx De-Identified	Policy
Antifungals - Itraconazole DQM Policy - Per Rx De-Identified	Policy
Antifungals - Noxafil (Oral) PA Policy De-Identified	Policy
Antifungals - Vivjoa PA Policy De-Identified	Policy
Antifungals - Voriconazole (Oral) PA Policy De-Identified	Policy
Antifungals (Azoles) - Intravenous Products PA Policy De-Identified	Policy
Antifungals for Vulvovaginal Candidiasis Step Therapy Policy De-Identified	Policy
Antiseizure Medications - Topiramate Step Therapy Policy De-Identified	Policy
Antiseizure Medications - Xcopri DQM Policy - Per Rx De-Identified	Policy
Antivirals - Famciclovir DQM Policy - Per Rx De-Identified	Policy
Antivirals - Ribavirin (Inhaled Products) PA Policy De-Identified	Policy
Antivirals - Ribavirin (Oral Products) PA Policy De-Identified	Policy
Antivirals - Valacyclovir DQM Policy - Per Rx De-Identified	Policy
Attention Deficit Hyperactivity Disorder Non-Stimulant Medications PA Policy De-Identified	Policy
Attention Deficit Hyperactivity Disorder Non-Stimulant Medications Step Therapy Policy De-Identified	Policy
Attention Deficit Hyperactivity Disorder Stimulant Medications PA Policy De-Identified	Policy
Attention Deficit Hyperactivity Disorder Stimulant Medications Step Therapy Policy De-Identified	Policy
Benign Prostatic Hyperplasia - 5-Alpha-Reductase Inhibitors Step Therapy Policy De-Identified	Policy
Benign Prostatic Hyperplasia - Alpha Blockers Step Therapy Policy De-Identified	Policy
Benign Prostatic Hyperplasia – Entadfi PA Policy De-Identified	Policy
Benzodiazepines - Diazepam (Oral) DQM Policy - Per Days De-Identified	Policy
Benzodiazepines DQM Policy for InMynd - Per Rx De-Identified	Policy
Beta Blocker Step Therapy Policy De-Identified	Policy
Bile Acid Sequestrants Step Therapy Policy De-Identified	Policy
Bisphosphonates (Oral) Enhanced Step Therapy Policy De-Identified	Policy
Bisphosphonates (Oral) Step Therapy Policy De-Identified	Policy
Bone Modifiers - Evenity PA Policy De-Identified	Policy
Bone Modifiers - Ibandronate Intravenous (Boniva IV) PA Policy De-Identified	Policy
Bone Modifiers - Prolia PA Policy De-Identified	Policy
Bone Modifiers - Teriparatide DQM Policy - Per Days De-Identified	Policy
Bone Modifiers - Teriparatide Products PA Policy De-Identified	Policy
Bone Modifiers - Tymlos PA Policy De-Identified	Policy
Bone Modifiers - Xgeva DQM Policy - Per Rx De-Identified	Policy
Bone Modifiers - Xgeva PA Policy De-Identified	Policy
Bone Modifiers - Zoledronic Acid (Reclast) PA Policy De-Identified	Policy
Botulinum Toxins - Botox PA Policy De-Identified	Policy
Botulinum Toxins - Dysport PA Policy De-Identified	Policy
Botulinum Toxins - Myobloc PA Policy De-Identified	Policy
Botulinum Toxins - Xeomin PA Policy De-Identified	Policy
Bowel Disease - Lubiprostone DQM Policy - Per Rx De-Identified	Policy
Bowel Disease – Opioid-Induced Constipation Products Preferred Step Therapy Policy De-Identified	Policy

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