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.

Repository Corticotropin - Cortrophin Gel PA Policy De-Identified	Policy
Rituximab Intravenous Products PA Policy De-Identified	Policy
Rituximab Intravenous Products PSM Policy De-Identified	Policy
Scenesse PA Policy De-Identified	Policy
Sedative Hypnotics DQM Policy - Per Days De-Identified	Policy
Sedative Hypnotics Step Therapy Policy De-Identified	Policy
Sickle Cell Disease - Adakveo PA Policy De-Identified	Policy
Sickle Cell Disease - Endari PA Policy De-Identified	Policy
Sickle Cell Disease - Hydroxyurea Products Preferred Step Therapy Policy De-Identified	Policy
Sickle Cell Disease - Oxbryta DQM Policy - Per Rx De-Identified	Policy
Sickle Cell Disease - Oxbryta PA Policy De-Identified	Policy
Somatostatin Analogs - Mycapssa PA Policy De-Identified	Policy
Somatostatin Analogs – Octreotide Immediate-Release Products PA Policy De-Identified	Policy
Somatostatin Analogs – Octreotide Immediate-Release Products PSM Policy De-Identified	Policy
Somatostatin Analogs – Sandostatin LAR Depot PA Policy De-Identified	Policy
Somatostatin Analogs – Signifor LAR PA Policy De-Identified	Policy
Somatostatin Analogs for Acromegaly PSM Policy De-Identified	Policy
Somavert PA Policy De-Identified	Policy
Spinal Muscular Atrophy - Evrysdi PA Policy De-Identified	Policy
Spinal Muscular Atrophy - Spinraza DQM Policy - Per Days De-Identified	Policy
Spinal Muscular Atrophy - Spinraza PA Policy De-Identified	Policy
Spinal Muscular Atrophy - Zolgensma PA Policy De-Identified	Policy
Synagis PA Policy De-Identified	Policy
Tasimelteon Products PA Policy De-Identified	Policy
Testosterone (injectable) Products PA Policy De-Identified	Policy
Testosterone (Oral, Topical, and Nasal) Products PA Policy De-Identified	Policy
Testosterone Products (Topical) DQM Policy - Per Rx De-Identified	Policy
Testosterone Undecanoate (Oral) DQM Policy - Per Rx De-Identified	Policy
Tetracyclines (Oral) Step Therapy Policy De-Identified	Policy
Thrombocytopenia - Doptelet DQM Policy - Per Rx De-Identified	Policy
Thrombocytopenia - Doptelet PA Policy De-Identified	Policy
Thrombocytopenia - Mulpleta PA Policy De-Identified	Policy
Thrombocytopenia - Nplate PA Policy De-Identified	Policy
Thrombocytopenia - Promacta PA Policy De-Identified	Policy
Thrombocytopenia - Tavalisse PA Policy De-Identified	Policy
Tolvaptan Products - Jynarque PA Policy De-Identified	Policy
Tolvaptan Products - Tolvaptan (Samsca) PA Policy De-Identified	Policy
Tolvaptan Products DQM Policy - Per Rx De-Identified	Policy
Topical Acne - Cleansers Step Therapy Policy De-Identified	Policy
Topical Acne - Kits Step Therapy Policy De-Identified	Policy
Topical Acne - Topical Products Step Therapy Policy De-Identified	Policy
Topical Acne - Winlevi PA Policy De-Identified	Policy
Topical Acyclovir Products PA Policy De-Identified	Policy
Topical Agents for Atopic Dermatitis DQM Policy - Per Days De-Identified	Policy
Topical Agents for Atopic Dermatitis Step Therapy Policy De-Identified	Policy
Topical Alpha-Adrenergic Agonists for Rosacea - Brimonidine PA with Step Therapy Policy De-Identified	Policy
Topical Alpha-Adrenergic Agonists for Rosacea - Rhofade PA Policy De-Identified	Policy
Topical Anesthetics DQM Policy - Per Days De-Identified	Policy
Topical Antibacterials Step Therapy Policy De-Identified	Policy
Topical Antibiotics for Acne - Clindamycin DQM Policy - Per Days De-Identified	Policy
Topical Antifungals DQM Policy - Per Days De-Identified	Policy
Topical Antifungals for Onychomycosis Step Therapy Policy De-Identified	Policy
Topical Antipruritics - Doxepin Products DQM Policy - Per Days De-Identified	Policy
Topical Calcipotriene Products DQM Policy - Per Days De-Identified	Policy
Topical Collagenase - Santyl DQM Policy - Per Rx De-Identified	Policy
Topical Corticosteroids - Clobetasol DQM Policy - Per Days De-Identified	Policy
Topical Corticosteroids - Diflorasone DQM Policy - Per Days De-Identified	Policy
Topical Corticosteroids - Fluocinonide DQM Policy - Per Days De-Identified	Policy
Topical Corticosteroids - Flurandrenolide DQM Policy - Per Days De-Identified	Policy
Topical Corticosteroids - Hydrocortisone Butyrate DQM Policy - Per Days De-Identified	Policy
Topical Corticosteroids - Triamcinolone Spray DQM Policy - Per Days De-Identified	Policy
Topical Corticosteroids Step Therapy Policy De-Identified	Policy
Topical Diclofenac Sodium 3 percent Gel PA Policy De-Identified	Policy
Topical Doxepin Step Therapy Policy De-Identified	Policy
Topical Medications for Inflammatory Rosacea Step Therapy De-Identified	Policy
Topical Podofilox Products Step Therapy Policy De-Identified	Policy
Topical Products - Vtama and Zoryve Step Therapy Policy De-Identified	Policy
Topical Retinoids - Aklief PA Policy De-Identified	Policy
Topical Retinoids - Panretin PA Policy De-Identified	Policy
Topical Retinoids - Tazarotene Products PA Policy De-Identified	Policy
Topical Retinoids - Tretinoin Products PA Policy De-Identified	Policy
Topical Vitamin D Analogs Step Therapy Policy De-Identified	Policy
Uplizna PA Policy De-Identified	Policy
Vasculitis - Tavneos PA Policy De-Identified	Policy
Vecamyl PA Policy De-Identified	Policy
Veregen PA Policy De-Identified	Policy
Vesicular Monoamine Transporter Type 2 Inhibitors - Austedo PA Policy De-Identified	Policy
Vesicular Monoamine Transporter Type 2 Inhibitors - Ingrezza PA Policy De-Identified	Policy
Vesicular Monoamine Transporter Type 2 Inhibitors - Tetrabenazine PA Policy De-Identified	Policy
Vesicular Monoamine Transporter Type 2 Inhibitors DQM Policy - Per Rx De-Identified	Policy
Vesicular Monoamine Transporter Type 2 Inhibitors PSM Policy De-Identified	Policy
Vijoice PA Policy De-Identified	Policy
Vitamin B12 (Cyanocobalamin) Products Step Therapy Policy De-Identified	Policy
Vitamin D Analog (Oral) Step Therapy Policy De-Identified	Policy
Wakefulness-Promoting Agents - Sunosi DQM Policy - Per Rx De-Identified	Policy
Wakefulness-Promoting Agents – Wakix DQM Policy – Per Rx De-Identified	Policy
Xiaflex PA Policy De-Identified	Policy
Zavesca Market Events Clinical Policy De-Identified	Policy
Zokinvy PA Policy De-Identified	Policy

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