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 (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 |
| Oncology (Injectable) - Topotecan Products PA Policy De-Identified | Policy |
| Oncology (Injectable) - Torisel PA Policy De-Identified | Policy |
| Oncology (Injectable) - Trastuzumab Products PA Policy De-Identified | Policy |
| Oncology (Injectable) - Trastuzumab Products PSM Policy De-Identified | Policy |
| Oncology (Injectable) - Trodelvy PA Policy De-Identified | Policy |
| Oncology (Injectable) - Unituxin PA Policy De-Identified | Policy |
| Oncology (Injectable) - Vectibix PA Policy De-Identified | Policy |
| Oncology (Injectable) - Vyxeos PA Policy De-Identified | Policy |
| Oncology (Injectable) - Yervoy PA Policy De-Identified | Policy |
| Oncology (Injectable) - Zaltrap PA Policy De-Identified | Policy |
| Oncology (Injectable) - Zepzelca PA Policy De-Identified | Policy |
| Oncology (Injectable) - Zynlonta PA Policy De-Identified | Policy |
| Oncology (Other) - Jelmyto PA Policy De-Identified | Policy |
| Oncology (Other) - Valrubicin Products 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 |
| Oncology - Calquence PA Policy De-Identified | Policy |
| Oncology - Capecitabine PA Policy De-Identified | Policy |
| Oncology - Capecitabine PSM Policy De-Identified | Policy |
| Oncology - Caprelsa PA Policy De-Identified | Policy |
| Oncology - Cometriq DQM Policy - Per Rx De-Identified | Policy |