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 - Cometriq PA Policy De-Identified | Policy |
| Oncology - Copiktra PA Policy De-Identified | Policy |
| Oncology - Cotellic PA Policy De-Identified | Policy |
| Oncology - Cyclin Dependent Kinases 4,6 Inhibitors PSM Policy De-Identified | Policy |
| Oncology - Daurismo PA Policy De-Identified | Policy |
| Oncology - Erivedge PA Policy De-Identified | Policy |
| Oncology - Erleada PA Policy De-Identified | Policy |
| Oncology - Erlotinib DQM Policy - Per Rx De-Identified | Policy |
| Oncology - Erlotinib PA Policy De-Identified | Policy |
| Oncology - Everolimus DQM Policy - Per Rx De-Identified | Policy |
| Oncology - Everolimus Products PA Policy De-Identified | Policy |
| Oncology - Everolimus Products PSM Policy De-Identified | Policy |
| Oncology - Exkivity PA Policy De-Identified | Policy |
| Oncology - Farydak PA Policy De-Identified | Policy |
| Oncology - Fotivda PA Policy De-Identified | Policy |
| Oncology - Gavreto DQM Policy - Per Rx De-Identified | Policy |
| Oncology - Gavreto PA Policy De-Identified | Policy |
| Oncology - Gilotrif PA Policy De-Identified | Policy |
| Oncology - Ibrance PA Policy De-Identified | Policy |
| Oncology - Iclusig PA Policy De-Identified | Policy |
| Oncology - Idhifa PA Policy De-Identified | Policy |
| Oncology - Imatinib DQM Policy - Per Rx De-Identified | Policy |
| Oncology - Imatinib PA Policy De-Identified | Policy |
| Oncology - Imatinib PSM Policy De-Identified | Policy |
| Oncology - Imbruvica PA Policy De-Identified | Policy |
| Oncology - Imbruvica PSM Policy De-Identified | Policy |
| Oncology - Inlyta PA Policy De-Identified | Policy |
| Oncology - Inqovi PA Policy De-Identified | Policy |
| Oncology - Inrebic PA Policy De-Identified | Policy |
| Oncology - Iressa DQM Policy - Per Rx De-Identified | Policy |
| Oncology - Iressa PA Policy De-Identified | Policy |
| Oncology - Jakafi PA Policy De-Identified | Policy |
| Oncology - Kisqali and Kisqali Femara Co-Pack PA Policy De-Identified | Policy |
| Oncology - Koselugo PA De-Identified | Policy |
| Oncology - Krazati PA Policy De-Identified | Policy |
| Oncology - Lapatinib DQM Policy - Per Rx De-Identified | Policy |
| Oncology - Lapatinib PA Policy De-Identified | Policy |
| Oncology - Lenalidomide PA Policy De-Identified | Policy |
| Oncology - Lenvima PA Policy De-Identified | Policy |
| Oncology - Lonsurf PA Policy De-Identified | Policy |
| Oncology - Lorbrena PA Policy De-Identified | Policy |
| Oncology - Lumakras PA Policy De-Identified | Policy |
| Oncology - Lynparza PA Policy De-Identified | Policy |
| Oncology - Lytgobi PA Policy De-Identified | Policy |
| Oncology - Mekinist PA Policy De-Identified | Policy |
| Oncology - Mektovi PA Policy De-Identified | Policy |
| Oncology - Nerlynx PA Policy De-Identified | Policy |
| Oncology - Nilutamide PA Policy De-Identified | Policy |
| Oncology - Ninlaro PA Policy De-Identified | Policy |
| Oncology - Nubeqa PA Policy De-Identified | Policy |
| Oncology - Odomzo PA Policy De-Identified | Policy |
| Oncology - Onureg PA Policy De-Identified | Policy |
| Oncology - Orgovyx DQM Policy - Per Rx De-Identified | Policy |
| Oncology - Orgovyx PA Policy De-Identified | Policy |
| Oncology - Pemazyre PA Policy De-Identified | Policy |
| Oncology - Piqray PA Policy De-Identified | Policy |
| Oncology - Pomalyst PA Policy De-Identified | Policy |
| Oncology - Qinlock DQM Policy - Per Rx De-Identified | Policy |
| Oncology - Qinlock PA Policy De-Identified | Policy |
| Oncology - Retevmo PA Policy De-Identified | Policy |
| Oncology - Rezlidhia PA Policy De-Identified | Policy |
| Oncology - Rozlytrek DQM Policy - Per Rx De-Identified | Policy |
| Oncology - Rozlytrek PA Policy De-Identified | Policy |
| Oncology - Rubraca PA Policy De-Identified | Policy |
| Oncology - Rydapt PA Policy De-Identified | Policy |
| Oncology - Scemblix PA Policy De-Identified | Policy |
| Oncology - Sorafenib PA Policy De-Identified | Policy |
| Oncology - Sorafenib PSM Policy De-Identified | Policy |
| Oncology - Sprycel DQM Policy - Per Rx De-Identified | Policy |
| Oncology - Sprycel PA Policy De-Identified | Policy |
| Oncology - Stivarga PA Policy De-Identified | Policy |
| Oncology - Sunitinib PA Policy De-Identified | Policy |
| Oncology - Sunitinib PSM Policy De-Identified | Policy |
| Oncology - Sutent DQM Policy - Per Rx De-Identified | Policy |
| Oncology - Tabrecta PA Policy De-Identified | Policy |
| Oncology - Tafinlar PA Policy De-Identified | Policy |
| Oncology - Tagrisso PA Policy De-Identified | Policy |
| Oncology - Talzenna PA Policy De-Identified | Policy |
| Oncology - Tasigna DQM Policy - Per Rx De-Identified | Policy |
| Oncology - Tasigna PA Policy De-Identified | Policy |
| Oncology - Tazverik PA Policy De-Identified | Policy |
| Oncology - Temozolomide Capsules PA Policy De-Identified | Policy |
| Oncology - Tepmetko PA Policy De-Identified | Policy |
| Oncology - Thalomid PA Policy De-Identified | Policy |
| Oncology - Tibsovo PA Policy De-Identified | Policy |
| Oncology - Truseltiq PA Policy De-Identified | Policy |
| Oncology - Tukysa PA Policy De-Identified | Policy |
| Oncology - Turalio PA Policy De-Identified | Policy |
| Oncology - Valchlor PA Policy De-Identified | Policy |
| Oncology - Venclexta DQM policy - Per Rx De-Identified | Policy |
| Oncology - Venclexta PA Policy De-Identified | Policy |
| Oncology - Verzenio PA Policy De-Identified | Policy |
| Oncology - Vistogard DQM Policy - Per Rx De-Identified | Policy |
| Oncology - Vistogard PA Policy De-Identified | Policy |
| Oncology - Vitrakvi DQM Policy - Per Rx De-Identified | Policy |
| Oncology - Vitrakvi PA Policy De-Identified | Policy |
| Oncology - Vizimpro PA Policy De-Identified | Policy |
| Oncology - Vonjo PA Policy De-Identified | Policy |
| Oncology - Votrient PA Policy De-Identified | Policy |
| Oncology - Welireg PA Policy De-Identified | Policy |