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.

Lupus - Lupkynis PA Policy De-Identified	Policy
Lupus - Saphnelo PA Policy De-Identified	Policy
Makena (Hydroxyprogesterone caproate) PA Policy De-Identified	Policy
Metabolic Disorders - Betaine Anhydrous PA Policy De-Identified	Policy
Metabolic Disorders - Carbaglu PA Policy De-Identified	Policy
Metabolic Disorders - Dojolvi PA Policy De-Identified	Policy
Metabolic Disorders - Imcivree DQM Policy - Per Days De-Identified	Policy
Metabolic Disorders - Imcivree PA Policy De-Identified	Policy
Metabolic Disorders - Nitisinone Products PA Policy De-Identified	Policy
Metabolic Disorders - Nulibry PA Policy De-Identified	Policy
Metabolic Disorders - Oxlumo PA Policy De-Identified	Policy
Metabolic Disorders - Tiopronin Products PA Policy De-Identified	Policy
Metabolic Disorders - Xuriden PA Policy De-Identified	Policy
Metabolic Disorders -Betaine Anhydrous PSM Policy De-Identified	Policy
Metabolic Disorders – Cysteamine Ophthalmic Solution PA Policy De-Identified	Policy
Metabolic Disorders – Phenylbutyrate Products PA Policy De-Identified	Policy
Methotrexate Injection Step Therapy Policy De-Identified	Policy
Migraine - Elyxyb PA Policy De-Identified	Policy
Migraine - Nurtec ODT PA Policy De-Identified	Policy
Migraine - Other Acute Medications DQM Policy - Per Rx De-Identified	Policy
Migraine - Qulipta PA Policy De-Identified	Policy
Migraine - Reyvow PA Policy De-Identified	Policy
Migraine - Ubrelvy PA Policy De-Identified	Policy
Migraine – Non-Steroidal Anti-Inflammatory Drugs DQM Policy – Per Days De-Identified	Policy
Migraine – Other Acute Medications DQM Policy – Per Days De-Identified	Policy
Migraine – Triptans DQM Policy – Per Days De-Identified	Policy
Migraine – Triptans DQM Policy – Per Rx De-Identified	Policy
Migraine Medication Step Therapy Policy De-Identified	Policy
Multiple Sclerosis - Aubagio PA Policy De-Identified	Policy
Multiple Sclerosis - Avonex PA Policy De-Identified	Policy
Multiple Sclerosis - Bafiertam PA Policy De-Identified	Policy
Multiple Sclerosis - Betaseron, Extavia PA Policy De-Identified	Policy
Multiple Sclerosis - Briumvi PA Policy De-Identified	Policy
Multiple Sclerosis - CD20-Directed Cytolytic Antibody Infused Products PSM Policy De-Identified	Policy
Multiple Sclerosis - Dalfampridine PA Policy De-Identified	Policy
Multiple Sclerosis - Dalfampridine PSM Policy De-Identified	Policy
Multiple Sclerosis - Dimethyl Fumarate PA Policy De-Identified	Policy
Multiple Sclerosis - Fingolimod PA Policy De-Identified	Policy
Multiple Sclerosis - Glatiramer Products PA Policy De-Identified	Policy
Multiple Sclerosis - Kesimpta DQM Policy - Per Days De-Identified	Policy
Multiple Sclerosis - Kesimpta PA Policy De-Identified	Policy
Multiple Sclerosis - Lemtrada DQM Policy - Per Days De-Identified	Policy
Multiple Sclerosis - Lemtrada PA Policy De-Identified	Policy
Multiple Sclerosis - Mavenclad PA Policy De-Identified	Policy
Multiple Sclerosis - Mayzent DQM Policy - Per Rx De-Identified	Policy
Multiple Sclerosis - Mayzent PA Policy De-Identified	Policy
Multiple Sclerosis - Ocrevus DQM Policy - Per Days De-Identified	Policy
Multiple Sclerosis - Ocrevus PA Policy De-Identified	Policy
Multiple Sclerosis - Plegridy PA Policy De-Identified	Policy
Multiple Sclerosis - Ponvory DQM Policy - Per Days De-Identified	Policy
Multiple Sclerosis - Ponvory PA Policy De-Identified	Policy
Multiple Sclerosis - Rebif PA Policy De-Identified	Policy
Multiple Sclerosis - Tascenso ODT PA Policy De-Identified	Policy
Multiple Sclerosis - Vumerity PA Policy De-Identified	Policy
Multiple Sclerosis and Crohn's Disease - Tysabri PA Policy De-Identified	Policy
Multiple Sclerosis and Ulcerative Colitis - Zeposia PA Policy De-Identified	Policy
Multiple Sclerosis and Ulcerative Colitis - Zeposia PSM Policy De-Identified	Policy
Multiple Sclerosis PSM Policy De-Identified	Policy
Muscular Dystrophy - Amondys 45 PA Policy De-Identified	Policy
Muscular Dystrophy - Emflaza PA Policy 2 De-Identified	Policy
Muscular Dystrophy - Emflaza PA Policy De-Identified	Policy
Muscular Dystrophy - Exondys 51 PA Policy De-Identified	Policy
Muscular Dystrophy - Viltepso PA Policy De-Identified	Policy
Muscular Dystrophy - Vyondys 53 PA Policy De-Identified	Policy
Naloxone Injection Step Therapy Policy De-Identified	Policy
Nasal Steroids Step Therapy Policy De-Identified	Policy
Natpara PA Policy De-Identified	Policy
Nephrology - Tarpeyo PA Policy De-Identified	Policy
Neurology - Aduhelm PA Policy De-Identified	Policy
Neurology - Brineura PA Policy De-Identified	Policy
Neurology - Gene Therapy - Skysona PA Policy De-Identified	Policy
Neurology - Leqembi PA Policy De-Identified	Policy
Neurology - Oxybate Products PA Policy De-Identified	Policy
Neurology - Radicava Products PA Policy De-Identified	Policy
Neurology - Relyvrio PA Policy De-Identified	Policy
Neurology - Riluzole Products PA Policy De-Identified	Policy
Neurology - Vyvgart PA Policy De-Identified	Policy
Nonsteroidal Anti-Inflammatory Drug - Tivorbex DQM Policy - Per Rx De-Identified	Policy
Nonsteroidal Anti-Inflammatory Drug Step Therapy Policy De-Identified	Policy
Northera PA Policy De-Identified	Policy
Nuedexta PA Policy De-Identified	Policy
Oncology - Abiraterone Acetate DQM Policy - Per Rx De-Identified	Policy
Oncology - Abiraterone Acetate PA Policy De-Identified	Policy
Oncology - Abiraterone Acetate PSM Policy De-Identified	Policy
Oncology - Alecensa PA Policy De-Identified	Policy
Oncology - Alunbrig DQM Policy - Per Rx De-Identified	Policy
Oncology - Alunbrig PA Policy De-Identified	Policy
Oncology - Ayvakit PA Policy De-Identified	Policy
Oncology - Balversa PA Policy De-Identified	Policy
Oncology - Bexarotene (Oral) PA Policy De-Identified	Policy
Oncology - Bexarotene (Oral) PSM Policy De-Identified	Policy
Oncology - Bexarotene (Topical) PA Policy De-Identified	Policy
Oncology - Bexarotene (Topical) PSM Policy De-Identified	Policy
Oncology - Bosulif DQM Policy - Per Rx De-Identified	Policy
Oncology - Bosulif PA Policy De-Identified	Policy
Oncology - Braftovi PA Policy De-Identified	Policy
Oncology - Brukinsa PA Policy De-Identified	Policy
Oncology - Cabometyx DQM Policy - Per Rx De-Identified	Policy
Oncology - Cabometyx PA Policy De-Identified	Policy
Oncology - Calquence DQM Policy - Per Rx De-Identified	Policy

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