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.
| Oncology - Vitrakvi PA Policy De-Identified | Policy |
| Oncology - Vizimpro PA Policy De-Identified | Policy |
| Oncology - Vonjo PA Policy De-Identified | Policy |
| Oncology - Votrient PA Policy De-Identified | Policy |
| Oncology - Welireg PA Policy De-Identified | Policy |
| Oncology - Xalkori DQM Policy - Per Rx De-Identified | Policy |
| Oncology - Xalkori PA Policy De-Identified | Policy |
| Oncology - Xermelo DQM Policy - Per Rx De-Identified | Policy |
| Oncology - Xermelo PA Policy De-Identified | Policy |
| Oncology - Xospata PA Policy De-Identified | Policy |
| Oncology - Xpovio PA Policy De-Identified | Policy |
| Oncology - Xtandi DQM Policy - Per Rx De-Identified | Policy |
| Oncology - Xtandi PA Policy De-Identified | Policy |
| Oncology - Yonsa PA Policy De-Identified | Policy |
| Oncology - Zejula PA Policy De-Identified | Policy |
| Oncology - Zelboraf PA Policy De-Identified | Policy |
| Oncology - Zolinza PA Policy De-Identified | Policy |
| Oncology - Zydelig PA Policy De-Identified | Policy |
| Oncology - Zykadia PA Policy De-Identified | Policy |
| Oncology (Injectable - CAR-T) - Abecma PA Policy De-Identified | Policy |
| Oncology (Injectable - CAR-T) - Breyanzi PA Policy De-Identified | Policy |
| Oncology (Injectable - CAR-T) - Carvykti PA Policy De-Identified | Policy |
| Oncology (Injectable - CAR-T) - Kymriah PA Policy De-Identified | Policy |
| Oncology (Injectable - CAR-T) - Tecartus PA Policy De-Identified | Policy |
| Oncology (Injectable - CAR-T) - Yescarta PA Policy De-Identified | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Jemperli PA Policy De-Identified | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Keytruda PA Policy De-Identified | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Libtayo PA Policy De-Identified | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Opdivo PA Policy De-Identified | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Opdualag PA Policy De-Identified | Policy |
| Oncology (Injectable - Programmed Death-Ligand 1) - Bavencio PA Policy De-Identified | Policy |
| Oncology (Injectable - Programmed Death-Ligand 1) - Imfinzi PA Policy De-Identified | Policy |
| Oncology (Injectable - Programmed Death-Ligand 1) - Tecentriq PA Policy De-Identified | Policy |
| Oncology (Injectable) - Adcetris PA Policy De-Identified | Policy |
| Oncology (Injectable) - Aliqopa PA Policy De-Identified | Policy |
| Oncology (Injectable) - Arsenic Trioxide PA Policy De-Identified | Policy |
| Oncology (Injectable) - Arzerra PA Policy De-Identified | Policy |
| Oncology (Injectable) - Asparlas PA Policy De-Identified | Policy |
| Oncology (Injectable) - Azedra PA Policy De-Identified | Policy |
| Oncology (Injectable) - Beleodaq PA Policy De-Identified | Policy |
| Oncology (Injectable) - Bendamustine Products PA Policy De-Identified | Policy |
| Oncology (Injectable) - Besponsa PA Policy De-Identified | Policy |
| Oncology (Injectable) - Besremi PA Policy De-Identified | Policy |
| Oncology (Injectable) - Bevacizumab Products PA Policy De-Identified | Policy |
| Oncology (Injectable) - Bevacizumab Products PSM Policy De-Identified | Policy |
| Oncology (Injectable) - Blenrep PA Policy De-Identified | Policy |
| Oncology (Injectable) - Blincyto PA Policy De-Identified | Policy |
| Oncology (Injectable) - Bortezomib PA Policy De-Identified | Policy |
| Oncology (Injectable) - Carmustine Products PA Policy De-Identified | Policy |
| Oncology (Injectable) - Cosela PA Policy De-Identified | Policy |
| Oncology (Injectable) - Cyramza PA Policy De-Identified | Policy |
| Oncology (Injectable) - Danyelza PA Policy De-Identified | Policy |
| Oncology (Injectable) - Darzalex Faspro PA Policy De-Identified | Policy |
| Oncology (Injectable) - Darzalex Intravenous PA Policy De-Identified | Policy |
| Oncology (Injectable) - Decitabine Products PA Policy De-Identified | Policy |
| Oncology (Injectable) - Elahere PA Policy De-Identified | Policy |
| Oncology (Injectable) - Elzonris PA Policy De-Identified | Policy |
| Oncology (Injectable) - Empliciti PA Policy De-Identified | Policy |
| Oncology (Injectable) - Enhertu PA Policy De-Identified | Policy |
| Oncology (Injectable) - Erbitux PA Policy De-Identified | Policy |
| Oncology (Injectable) - Erwinaze PA Policy De-Identified | Policy |
| Oncology (Injectable) - Fyarro PA Policy De-Identified | Policy |
| Oncology (Injectable) - Gazyva PA Policy De-Identified | Policy |
| Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PA Policy De-Identified | Policy |
| Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PSM policy De-Identified | Policy |
| Oncology (Injectable) - Halaven PA Policy De-Identified | Policy |
| Oncology (Injectable) - Herceptin Hylecta PA Policy De-Identified | Policy |
| Oncology (Injectable) - Imjudo PA Policy De-Identified | Policy |
| Oncology (Injectable) - Imlygic PA Policy De-Identified | Policy |
| Oncology (Injectable) - Ixempra PA Policy De-Identified | Policy |
| Oncology (Injectable) - Jevtana PA Policy De-Identified | Policy |
| Oncology (Injectable) - Kadcyla PA Policy De-Identified | Policy |
| Oncology (Injectable) - Kimmtrak PA Policy De-Identified | Policy |
| Oncology (Injectable) - Kyprolis PA Policy De-Identified | Policy |
| Oncology (Injectable) - Levoleucovorin Products PA Policy De-Identified | Policy |
| Oncology (Injectable) - Lumoxiti PA Policy De-Identified | Policy |
| Oncology (Injectable) - Lunsumio PA Policy De-Identified | Policy |
| Oncology (Injectable) - Margenza PA Policy De-Identified | Policy |
| Oncology (Injectable) - Monjuvi PA Policy De-Identified | Policy |
| Oncology (Injectable) - Mylotarg PA Policy De-Identified | Policy |
| Oncology (Injectable) - Oncaspar PA Policy De-Identified | Policy |
| Oncology (Injectable) - Onivyde PA Policy De-Identified | Policy |
| Oncology (Injectable) - Padcev PA Policy De-Identified | Policy |
| Oncology (Injectable) - Perjeta PA Policy De-Identified | Policy |
| Oncology (Injectable) - Phesgo PA Policy De-Identified | Policy |
| Oncology (Injectable) - Polivy PA Policy De-Identified | Policy |
| Oncology (Injectable) - Portrazza PA Policy De-Identified | Policy |
| Oncology (Injectable) - Poteligeo PA Policy De-Identified | Policy |
| Oncology (Injectable) - Pralatrexate Products PA Policy De-Identified | Policy |
| Oncology (Injectable) - Proleukin PA Policy De-Identified | Policy |
| Oncology (Injectable) - Rituxan Hycela PA Policy De-Identified | Policy |
| Oncology (Injectable) - Romidepsin Products PA Policy De-Identified | Policy |
| Oncology (Injectable) - Rybrevant PA Policy De-Identified | Policy |
| Oncology (Injectable) - Rylaze PA Policy De-Identified | Policy |
| Oncology (Injectable) - Sarclisa PA Policy De-Identified | Policy |
| Oncology (Injectable) - Sylvant PA Policy De-Identified | Policy |
| Oncology (Injectable) - Synribo PA Policy De-Identified | Policy |
| Oncology (Injectable) - Tecvayli PA Policy De-Identified | Policy |
| Oncology (Injectable) - Thiotepa Products PA Policy De-Identified | Policy |
| Oncology (Injectable) - Tivdak PA Policy De-Identified | Policy |