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.

Cabergoline DQM Policy - Per Days De-Identified	Policy
Calcitonin Gene-Related Peptide Inhibitors - Aimovig DQM Policy - Per Days De-Identified	Policy
Calcitonin Gene-Related Peptide Inhibitors - Aimovig PA Policy De-Identified	Policy
Calcitonin Gene-Related Peptide Inhibitors - Ajovy PA Policy De-Identified	Policy
Calcitonin Gene-Related Peptide Inhibitors - Emgality DQM Policy - Per Days De-Identified	Policy
Calcitonin Gene-Related Peptide Inhibitors - Emgality PA Policy De-Identified	Policy
Calcitonin Gene-Related Peptide Inhibitors - Vyepti PA Policy De-Identified	Policy
Calcium Channel Blockers-Dihydropyridine Products Step Therapy Policy De-Identified	Policy
Calcium Channel Blockers-Verapamil Products Step Therapy Policy De-Identified	Policy
Carbinoxamine Step Therapy Policy De-Identified	Policy
Cardiology - Camzyos PA Policy De-Identified	Policy
Cardiology - Corlanor PA Policy De-Identified	Policy
Cardiology - Ranolazine Products Step Therapy Policy De-Identified	Policy
Cardiology - Verquvo DQM Policy - Per Rx De-Identified	Policy
Cardiology - Zontivity PA Policy De-Identified	Policy
Chelating Agents - Chemet PA Policy De-Identified	Policy
Chelating Agents - Iron Chelators (Oral) PA Policy De-Identified	Policy
Chelating Agents - Trientine PA Policy De-Identified	Policy
Chelating Agents – Iron Chelators (Oral) PSM Policy De-Identified	Policy
Chenodal PA Policy De-Identified	Policy
Cholbam PA Policy De-Identified	Policy
Chorionic Gonadotropins DQM Policy - Per Rx De-Identified	Policy
Chorionic Gonadotropins PSM Policy De-Identified	Policy
Cinacalcet PA De-Identified	Policy
Colchicine Products Preferred Step Therapy Policy De-Identified	Policy
Colony Stimulating Factors - Filgrastim Products PA Policy De-Identified	Policy
Colony Stimulating Factors - Filgrastim Products PSM Policy for High Performance Formulary, effective 01 De-Identified	Policy
Colony Stimulating Factors - Filgrastim Products PSM Policy for National Preferred Formulary and Basic Formulary De-Identified	Policy
Colony Stimulating Factors - Granix PA Policy De-Identified	Policy
Colony Stimulating Factors - Leukine PA Policy De-Identified	Policy
Colony Stimulating Factors - Pegfilgrastim Products and Rolvedon PSM Policy De-Identified	Policy
Colony Stimulating Factors - Pegfilgrastim Products PA Policy De-Identified	Policy
Colony Stimulating Factors - Pegfilgrastim Products PSM Policy De-Identified	Policy
Colony Stimulating Factors - Rolvedon PA Policy De-Identified	Policy
Complement Inhibitors - Empaveli PA Policy De-Identified	Policy
Complement Inhibitors – Soliris PA Policy De-Identified	Policy
Complement Inhibitors – Ultomiris Intravenous PA Policy De-Identified	Policy
Complement Inhibitors – Ultomiris Subcutaneous PA Policy De-Identified	Policy
Contraceptives - Oral, Patch, and Vaginal Ring Products Step Therapy Policy De-Identified	Policy
Contraceptives - Phexxi PA Policy De-Identified	Policy
Coronavirus – Oral Medications for Treatment of COVID-19 DQM Policy – Per Days De-Identified	Policy
Coronavirus Disease - Evusheld PA Policy De-Identified	Policy
Coronavirus Disease - Veklury PA Policy De-Identified	Policy
Corticosteroids (Intraarticular) - Zilretta PA Policy De-Identified	Policy
Corticosteroids (Nasal) - Mometasone DQM Policy - Per Rx De-Identified	Policy
Corticosteroids (Nebulized) - Budesonide DQM Policy - Per Rx De-Identified	Policy
Crysvita PA Policy De-Identified	Policy
Cushing's - Isturisa PA Policy De-Identified	Policy
Cushing's - Korlym PA Policy De-Identified	Policy
Cushing's - Recorlev PA Policy De-Identified	Policy
Cushing's - Signifor PA Policy De-Identified	Policy
Cushing's Disease - Isturisa DQM Policy - Per Rx De-Identified	Policy
Cyclooxygenase-2 Inhibitor Step Therapy Policy De-Identified	Policy
Cystic Fibrosis - Bronchitol PA Policy De-Identified	Policy
Cystic Fibrosis - Kalydeco PA Policy De-Identified	Policy
Cystic Fibrosis - Orkambi PA Policy De-Identified	Policy
Cystic Fibrosis - Pulmozyme PA Policy De-Identified	Policy
Cystic Fibrosis - Symdeko PA Policy De-Identified	Policy
Cystic Fibrosis - Trikafta PA Policy De-Identified	Policy
Dermatology - Hyftor PA De-Identified	Policy
Dermatology - Opzelura PA Policy De-Identified	Policy
Dermatology - Vtama DQM Policy - Per Days De-Identified	Policy
Dermatology - Zoryve DQM Policy - Per Days De-Identified	Policy
Desmopressin Products - Nocdurna PA Policy De-Identified	Policy
Diabetes - Canagliflozin Products DQM Policy - Per Rx De-Identified	Policy
Diabetes - Continuous Glucose Monitoring Systems PA Policy De-Identified	Policy
Diabetes - Dipeptidyl Peptidase-4 Inhibitors Preferred Step Therapy Policy De-Identified	Policy
Diabetes - Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy De-Identified	Policy
Diabetes - Glucagon-Like Peptide-1 Agonists PA Policy De-Identified	Policy
Diabetes - Kerendia PA Policy De-Identified	Policy
Diabetes - Metformin Extended-Release DQM Policy - Per Rx De-Identified	Policy
Diabetes - Metformin Step Therapy Policy De-Identified	Policy
Diabetes - Mounjaro PA Policy De-Identified	Policy
Diabetes - Omnipods DQM Policy - Per Days De-Identified	Policy
Diabetes - Sodium Glucose Co-Transporter-2 and Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy De-Identified	Policy
Diabetes - Sodium Glucose Co-Transporter-2 Inhibitors Step Therapy Policy De-Identified	Policy
Diabetes - Symlin PA Policy De-Identified	Policy
Diabetes - Thiazolidinedione Step Therapy Policy De-Identified	Policy
Diabetes - Tzield PA Policy De-Identified	Policy
Diuretics - Loop Products Step Therapy Policy De-Identified	Policy
Enspryng PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Aldurazyme PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Elaprase PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Fabrazyme PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Kanuma PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Lumizyme PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Mepsevii PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Naglazyme PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Nexviazyme PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Revcovi PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Strensiq PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Sucraid PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Vimizim PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Xenpozyme PA Policy De-Identified	Policy
Epinephrine Auto-Injectors Preferred Step Therapy Policy 2 De-Identified	Policy
Epinephrine Auto-injectors Preferred Step Therapy Policy De-Identified	Policy
Epinephrine Auto-Injectors Step Therapy Policy De-Identified	Policy
Erythropoiesis-Stimulating Agents - Aranesp PA Policy De-Identified	Policy
Erythropoiesis-Stimulating Agents - Epoetin Alfa Products PA Policy De-Identified	Policy
Erythropoiesis-Stimulating Agents - Mircera PA Policy De-Identified	Policy

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