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.

Hyperlipidemia - Omega-3 Fatty Acid Products PA Policy De-Identified	Policy
Hypertension - Clonidine Patches DQM Policy - Per Days De-Identified	Policy
Hypoactive Sexual Desire Disorder - Addyi PA Policy De-Identified	Policy
Hypoactive Sexual Desire Disorder - Vyleesi PA Policy De-Identified	Policy
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Ofev PA Policy De-Identified	Policy
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Pirfenidone PA Policy De-Identified	Policy
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Pirfenidone PSM Policy De-Identified	Policy
Immune Globulin - Atgam PA Policy De-Identified	Policy
Immune Globulin - Intravenous PA Policy De-Identified	Policy
Immune Globulin - Subcutaneous PA Policy De-Identified	Policy
Immune Globulin – Cytogam PA Policy De-Identified	Policy
Immunologicals - Adbry DQM Policy - Per Days De-Identified	Policy
Immunologicals - Adbry PA Policy De-Identified	Policy
Immunologicals - Anti-Interleukin-5 Agents PSM Policy De-Identified	Policy
Immunologicals - Dupixent DQM Policy - Per Days De-Identified	Policy
Immunologicals - Dupixent PA Policy De-Identified	Policy
Immunologicals - Fasenra DQM Policy - Per Days De-Identified	Policy
Immunologicals - Nucala DQM Policy - Per Days De-Identified	Policy
Immunologicals - Nucala PA Policy De-Identified	Policy
Immunologicals - Tezspire PA Policy De-Identified	Policy
Immunologicals - Xolair DQM Policy - Per Days De-Identified	Policy
Immunologicals – Cinqair PA Policy De-Identified	Policy
Immunologicals – Fasenra PA Policy De-Identified	Policy
Immunologicals – Xolair PA Policy De-Identified	Policy
Immunosuppressive Agents - Rezurock DQM Policy - Per Rx De-Identified	Policy
Immunosuppressive Agents - Rezurock PA Policy De-Identified	Policy
Infectious Disease - Antiparasitic Agents DQM Policy - Per Days De-Identified	Policy
Infectious Disease - Antiparasitics DQM Policy - Per Days De-Identified	Policy
Infectious Disease - Impavido PA Policy De-Identified	Policy
Infectious Disease - Ivermectin Tablets PA Policy De-Identified	Policy
Infectious Disease - Livtencity DQM Policy - Per Days De-Identified	Policy
Infectious Disease - Livtencity PA Policy De-Identified	Policy
Infectious Disease - Pretomanid PA Policy De-Identified	Policy
Infectious Disease - Prevymis DQM Policy - Per Days De-Identified	Policy
Infectious Disease - Pyrimethamine PA Policy De-Identified	Policy
Infectious Disease - Sirturo PA Policy De-Identified	Policy
Infectious Disease - Vancomycin (Oral) DQM Policy - Per Rx De-Identified	Policy
Inflammatory Conditions - Actemra Intravenous PA Policy De-Identified	Policy
Inflammatory Conditions - Actemra Subcutaneous PA Policy De-Identified	Policy
Inflammatory Conditions - Adalimumab Products DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Adalimumab Products PA Policy De-Identified	Policy
Inflammatory Conditions - Arcalyst DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Arcalyst PA Policy De-Identified	Policy
Inflammatory Conditions - Cibinqo PA Policy De-Identified	Policy
Inflammatory Conditions - Cimzia DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Cimzia PA Policy De-Identified	Policy
Inflammatory Conditions - Cosentyx DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Cosentyx PA Policy De-Identified	Policy
Inflammatory Conditions - Entyvio Intravenous PA Policy De-Identified	Policy
Inflammatory Conditions - Etanercept Products DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Etanercept Products PA Policy De-Identified	Policy
Inflammatory Conditions - Ilaris PA Policy De-Identified	Policy
Inflammatory Conditions - Ilumya DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Ilumya PA Policy De-Identified	Policy
Inflammatory Conditions - Infliximab Products PA Policy De-Identified	Policy
Inflammatory Conditions - Kevzara PA Policy De-Identified	Policy
Inflammatory Conditions - Kineret DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Kineret PA Policy De-Identified	Policy
Inflammatory Conditions - Olumiant DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Olumiant PA Policy De-Identified	Policy
Inflammatory Conditions - Orencia Intravenous PA Policy De-Identified	Policy
Inflammatory Conditions - Orencia Subcutaneous PA Policy De-Identified	Policy
Inflammatory Conditions - Otezla DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Otezla PA Policy De-Identified	Policy
Inflammatory Conditions - Rinvoq DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Rinvoq PA Policy De-Identified	Policy
Inflammatory Conditions - Siliq DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Siliq PA Policy De-Identified	Policy
Inflammatory Conditions - Simponi Aria PA Policy De-Identified	Policy
Inflammatory Conditions - Simponi Subcutaneous DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Simponi Subcutaneous PA Policy De-Identified	Policy
Inflammatory Conditions - Skyrizi Subcutaneous DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Skyrizi Subcutaneous PA Policy De-Identified	Policy
Inflammatory Conditions - Sotyktu PA Policy De-Identified	Policy
Inflammatory Conditions - Spevigo PA Policy De-Identified	Policy
Inflammatory Conditions - Stelara Intravenous PA Policy De-Identified	Policy
Inflammatory Conditions - Stelara Subcutaneous DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Stelara Subcutaneous PA Policy with Dosing De-Identified	Policy
Inflammatory Conditions - Taltz DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Taltz PA Policy De-Identified	Policy
Inflammatory Conditions - Tremfya DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Tremfya PA Policy De-Identified	Policy
Inflammatory Conditions - Xeljanz Xeljanz XR PA Policy De-Identified	Policy
Inflammatory Conditions PSM Policy De-Identified	Policy
Interferon - Actimmune PA Policy De-Identified	Policy
Interleukin-1 Blockers for Cryopyrin-Associated Periodic Syndromes PSM Policy De-Identified	Policy
Iron Replacement – Feraheme PA Policy De-Identified	Policy
Iron Replacement – Ferrlecit PA Policy De-Identified	Policy
Iron Replacement – INFeD PA Policy De-Identified	Policy
Iron Replacement – Injectafer PA Policy De-Identified	Policy
Iron Replacement – Monoferric PA Policy De-Identified	Policy
Iron Replacement – Venofer PA Policy De-Identified	Policy
Isotretinoin Step Therapy Policy De-Identified	Policy
Keveyis PA Policy De-Identified	Policy
Lipodystrophy - Egrifta PA Policy De-Identified	Policy
Lipodystrophy - Myalept PA Policy De-Identified	Policy
Lucemyra PA Policy De-Identified	Policy
Lupus - Benlysta Intravenous PA Policy De-Identified	Policy
Lupus - Benlysta Subcutaneous DQM Policy - Per Days De-Identified	Policy
Lupus - Benlysta Subcutaneous PA Policy De-Identified	Policy

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