CareSource Drug List Coverage & Prior Auth

General Coverage

Covered when ALL of the following are met

General coverage conditions: Member's prescriber states the drug is medically necessary and the prescription is filled at a HAP CareSource MI Health Link network pharmacy.

Coverage subject to additional requirements such as prior authorization (PA), quantity limits (QL), step therapy (ST), or other utilization controls shown on the Drug List.

New Member Transition Supply

Covered when ANY of the following transition conditions are met

Temporary 30-day supply for new members: Member is within the first 90 days of plan membership and needs a temporary supply of a drug not on the Drug List.30-day supply

Multiple refills may be provided to reach the 30-day maximum; long‑term care members may be eligible for a one‑time 31‑day supply per policy; applies when plan rules, PA, or ST prevent immediate access.

Coverage when plan rules limit access: The drug is not on the Drug List, or plan rules prevent the member from receiving the amount prescribed by the prescriber.30-day supply

Policy permits temporary coverage during first 90 days to allow time for prescriber to pursue alternatives or an exception request.

Coverage when prior authorization or step therapy is required: The drug requires prior authorization (PA) or is subject to step therapy (ST) and the member needs immediate access during transition into the plan.30-day supply

Temporary supply provided while PA/ST processes or exception requests are completed.

Standard coverage conditions

Covered when plan rules are followed and any required authorizations are obtained

Plan coverage conditions: Member follows plan rules; prescriber obtains required prior authorization when indicated; the drug is on the plan Drug List or an exception has been granted.

If prior authorization is not obtained when required, the drug may not be covered; expedited exception decisions are available with prescriber support (24 hours); standard decisions within 72 hours after prescriber statement.

Covered with criteria

Coverage for listed antineoplastic/immunosuppressant products is conditional on meeting the listed utilization controls for each product (e.g., PA, MO, QL).

General formulary conditions: For any antineoplastic or immunosuppressant product listed, coverage is provided when specified utilization management items are satisfied: Prior Authorization (PA) obtained when indicated; Medical Oncology (MO) involvement where required; and adherence to Quantity Limits (QL) and any other line-specific flags (LA, B/D PA, NDS).

Specific QL values, PA/B/D PA, MO, LA, and NDS flags vary by product and are shown on each formulary row.

Per-drug coverage controls

Drugs listed are covered subject to the following conditions shown on each row

Per-drug coverage controls: Each drug formulary entry shows a tier level and required actions/restrictions (examples: PA, B/D PA, MO, LA, NDS). Where present a Quantity Limit (QL) is specified as an exact number per period (e.g., per 28 or 30 days).

Coverage for the drug presentation requires meeting the row-specific controls (obtain PA when listed; do not exceed QL).

Covered with conditions

Formulary coverage with utilization management controls

Formulary coverage: A listed drug/formulation is covered subject to the specific tier and utilization controls shown on its formulary line (PA, MO, LA, QL, NDS).

When PA, LA, or MO are present on the row, prior approval or specialty involvement is required before coverage; QL values must be followed as stated.

Coverage by formulary listing (partial)

Covered when listed on formulary with noted utilization controls and tier assignment

Formulary listing: Drug formulation is listed in the formulary fragment and assigned a Tier Level (e.g., 1 or 2) and may include utilization-control codes such as MO, ADD, QL, NDS.

Presence on the formulary implies coverage subject to the listed utilization requirements; consult the table legend and row-specific notes for exact requirements.

Formulary entries with utilization controls

Coverage and utilization controls are shown per drug/formulation row; coverage stance implied by presence on the formulary with a tier level and utilization controls.

Formulary row example - ARISTADA: ARISTADA intramuscular suspension and syringe presentations are listed with tier assignments and utilization controls such as MO and QL (examples include QL 2.4 per 28 days; QL 30 per 30 days; NDS).QL as specified per row

Coverage requires meeting the utilization controls shown for the specific presentation.

Example - armodafinil: Armodafinil formulations are listed with tier and controls and may require PA and QL (e.g., QL 30 per 30 days) as indicated on the row.QL 30/30 when listed

Obtain PA when the row indicates 'PA'.

Example - diazepam formulations: Diazepam formulations (injection, solution, tablets) appear with PA and/or MO and QL values that differ by formulation (liquid formulations may show higher QL values).

Formulary lines with utilization controls

Coverage and utilization controls for each listed product presentation are specified by tier and may require one or more controls:

controls: Each formulary line includes a Tier Level and may include one or more of: PA (Prior Authorization), MO (Medical Override/medical specialty requirement), QL (Quantity Limit), NDS (non‑standard dosing/distribution), LA (Limited Access), B/D PA (billing/dispensing PA), or ADD (non‑Part D/other).

See the specific formulary row for which controls apply; compliance with listed controls is required for coverage.

If the FDA or a manufacturer removes a drug from the market or determines it is unsafe or ineffective, the plan may immediately remove that drug from the Drug List and it will not be covered. The plan will notify affected members and providers after the change and members or prescribers may request an exception as described in the Drug List materials.

Entries marked ADD on the Drug List denote Non‑Part D drugs or OTC items covered by Medicaid only. These products follow different appeal rules and the member’s cost for ADD items does not count toward Part D catastrophic coverage. For items flagged B/D PA, the entry indicates the drug may be covered under Medicare Part B or Part D depending on the clinical circumstances and additional information (for example, site of service) may be required to determine benefit responsibility.

The provided excerpt is primarily the formulary table showing drug names, tiers and utilization flags (e.g., PA, MO, QL, NDS). No explicit clinical coverage criteria or policy-level exclusions (diagnosis‑based medical necessity rules) are present in these chunks; coverage for listed products is expressed as formulary entries with administrative controls that must be met for coverage.

Within this excerpt there are no explicit exclusion statements that list drugs or conditions denied coverage; the pages shown are formulary rows with utilization-control flags and the document repeatedly directs readers to the front of the table for symbol definitions.

The fragments reviewed do not define specific exclusion conditions. They present product rows with utilization markers (PA, MO, QL, NDS, LA) but do not list clinical exclusion criteria in the selected chunks.

No explicit exclusion criteria are listed in the shown formulary pages; entries identify required actions or limits (for example PA or QL) rather than documenting specific clinical scenarios in which a drug would be excluded from coverage.

The extract is limited to formulary listings and utilization-control annotations and does not contain statements labeling items 'not covered' or 'not medically necessary'. Do not infer noncoverage from the absence of a listing in these pages.

No explicit exclusions are provided in these chunks; the table uses symbols and abbreviations for utilization controls and refers readers back to the beginning of the table for exact symbol meanings rather than listing exclusion rules on these pages.

This fragment is primarily a formulary table listing covered products with tier assignments and utilization controls (e.g., MO, QL, NDS, ADD). It does not contain explicit exclusion language within the provided rows.

No explicit exclusion rules are stated in the supplied chunks; the rows show products with required actions and limits (PA, MO, QL, NDS) and the document directs readers to the table legend at the front for definitions.

In the excerpt provided there are no explicit exclusions listed. The pages note that symbol meanings and any conditions are defined at the start of the full table; readers should consult the full Drug List front matter for legend definitions and any exclusion language not present here.

The excerpt does not include New Medical Necessity (NMN) clinical scenarios. It does describe temporary transition supplies for new members elsewhere in the document, but within these chunks no NMN scenarios or clinical rationales are provided.

There are no explicit 'not medically necessary' statements

The reviewed fragments do not include any statements that label treatments as 'Not Medically Necessary.' Where utilization controls appear (PA, QL, LA), they indicate prior approval or access limits rather than NMN determinations in these chunks.

No 'Not Medically Necessary' language appears in these chunks. The pages focus on product lines, tiers and utilization-control flags; clinical NMN determinations are not present in the excerpt.

These formulary pages do not show explicit 'Not Medically Necessary' statements. Instead, they list products with tiering and controls (e.g., PA, QL, ADD) and point readers to the full table legend for definitions.

The provided fragment is a portion of the Drug List table and does not contain explicit 'not medically necessary' statements. Coverage stance in this excerpt is represented by presence on the formulary plus any listed utilization controls.

This fragment is predominantly a formulary table and does not include explicit NMN statements. The rows show required actions and limits (for example, PA or QL) that determine coverage when met.

The Drug List pages use a set of abbreviations and flags to communicate utilization controls. The legend shown at the start of the table defines 9 abbreviations used throughout (for example: ADD, B/D PA, LA, MO, NDS, PA, QL, ST, V), which readers should reference to interpret each formulary row.

Coding, Abbreviations and Quantity Examples

Example quantity limits

QL examples (antifungals)QL (96 per 30 days); QL (120 per 30 days)

NDS retail limitNDS = 30-day retail limit

Representative entries sourceSee antifungal entries showing 'MO; QL (96 per 30 days); NDS' and itraconazole 'MO; QL (120 per 30 days)'

Example quantity limits

Multiple-period QLsQL (84 per 56 days); QL (20 per 10 days)

Per-28-day examplesQL (224 per 28 days); QL (280 per 28 days)

Short-interval QLQL (10 per 10 days)

Quantity limits examples

COMETRIQ examplesQL (112 per 28 days); QL (84 per 28 days)

COTELLIC exampleQL (63 per 28 days)

Everolimus examplesQL (330 per 30 days); QL (240 per 30 days); QL (21 per 28 days); QL (84 per 28 days)

Somatuline quantity limit

Somatuline Depot QLQL (840 per 28 days)

FormulationSomatuline Depot subcutaneous syringe 60 mg/0.2 mL, 90 mg/0.3 mL

Utilization controlsPA; MO; NDS (per formulary lines)

Pemetrexed quantity limit

Pemetrexed QLQL (60 per 30 days)

ContextListed under antineoplastic/immunosuppressant entries with PA; MO flags

TimeframePer 30 days as shown on formulary table

Revlimid quantity limits

Revlimid QL (28-day)QL (28 per 28 days)

Revlimid QL (30-day)QL (120 per 30 days)

Utilization flagsPA; MO; LA; NDS as indicated on lines

Example quantity limits (antineoplastics)

Varied antineoplastic QLsExamples across entries include QL (90 per 30 days); QL (336 per 28 days); QL (840 per 28 days)

Additional examplesQL (60 per 30 days); QL (180 per 30 days); QL (300 per 30 days)

ContextValues appear with PA/MO/NDS flags per product row

Quantity limits range

Low to very high QLsQL examples include 10 per 30 days; 60 per 30 days; 360 per 30 days

Very high QLsQL (720 per 30 days); QL (1100 per 30 days)

Use noteThese limits vary by formulation and appear with PA/MO/NDS flags

Quantity limits examples

Mixed QL examplesQL (56 per 28 days); QL (30 per 30 days); QL (300 per 30 days)

Small-period QLsQL (8 per 28 days); QL (1 per 30 days); QL (2 per 30 days)

Large QLs notedQL (4500 per 30 days) shown for some formulations

Quantity limit examples (varied formulations)

Examples across opioid/analgesic linesQL (60 per 30 days); QL (4 per 28 days); QL (360 per 30 days)

Very large QLsQL (240 per 30 days); QL (5550 per 30 days); QL (1200 per 30 days); QL (2400 per 30 days)

ContextShown with PA/MO/NDS and formulation-specific notes

Topical and miscellaneous QLs

Topical diclofenac QLsdiclofenac sodium topical gel QL (1000 per 28 days); diclofenac topical solution QL (224 per 28 days)

JOURNAVXQL (30 per 90 days)

NoteEntries include MO/ADD flags alongside QLs

Assorted quantity limits

Assorted QL entriesExamples include QL (240 per 30 days); QL (3.2 per 56 days); QL (30 per 30 days)

Fractional/annual examplesQL (4.8 per 365 days); QL (3.9 per 56 days)

High monthly QLQL (240 per 30 days) shown for some injectable/tablet lines

Fractional / partial quantity limits

Fractional dose QLsQL (0.25 per 28 days); QL (0.5 per 28 days); QL (0.88 per 90 days)

Long-interval QLsQL (1.75 per 90 days); QL (2.63 per 90 days)

ContextUsed for long-acting injectable products (syringe volumes per period)

High QL example

High injectable QL exampleQL (540 per 30 days) — shown for one intramuscular suspension line

ContextAppears on intramuscular suspension/formulation rows with MO/PA flags

ReferenceSee risperidone/intramuscular suspension entries in table

Provider Responsibilities and Utilization Controls

Prior Authorization
Prior Authorization Required
Prior authorization (PA) is required for many drugs listed on the Drug List. When a PA flag appears in the "Necessary Actions, Restrictions, or Limit On Use" column the prescriber or pharmacy must obtain approval from CareSource (HAP CareSource MI Health Link) before dispensing; failure to obtain PA may result in the drug not being covered or a claim denial. Quantity limits (QL) and other utilization-control flags (MO, LA, NDS, B/D PA, ST, ADD) shown in the table may also restrict coverage and trigger prior review.
PA flags in the drug table indicate prior authorization is required before dispensing.
Many products also have QL (e.g., QL 28 per 28 days, QL 60 per 30 days) and NDS (limits supplies to retail or mail-order durations) that must be met.
B/D PA indicates the drug may be covered under Medicare Part B or Part D depending on use/setting; additional information may be required.
MO indicates Mail-Order availability; LA indicates limited availability at select pharmacies; ADD denotes Non‑Part D or OTC items with special appeal rules.
ST (Step Therapy) appears for select products (e.g., AUVELITY, some diazepam and OPIPZA oral film entries) and requires trying preferred agents first, unless an exception is granted.
Some formulations specifically list PA (for example: certain antimicrobial IV/inhlation formulations, antineoplastic/immunosuppressant oral, injectable, or kit formulations, and select CNS formulations such as diazepam oral solution) — ensure the claim matches the listed formulation and dosing units.
Antineoplastic and immunosuppressant agents frequently require PA and may have specialty, LA, MO, QL, and NDS controls; some require oncology/specialty review or B/D PA.

Documentation Required
Utilization Controls and Documentation
Utilization management flags in the drug table drive required documentation and authorizations. The table legend defines abbreviations (PA, QL, MO, LA, NDS, ST, B/D PA, ADD) — refer to the legend when preparing requests. Claims may be denied or delayed if required utilization controls are not satisfied.
Document the exact formulation, strength, and days' supply that match the table entry when submitting PA or exceptions.
Provide supporting clinical documentation when requesting exceptions to PA, QL, or ST rules; prescriber supporting statements are required for exception decisions.
Expedited (urgent) exception requests require a prescriber's supporting statement and will be decided within 24 hours; standard exception decisions are within 72 hours.
When QL or ST are not met, submit an exception request with clinical rationale to avoid denial.
Refer to the table legend (List of Abbreviations) for meaning of program flags before submitting authorizations.

Denial Risk
Provider Responsibilities to Prevent Denials
Provider actions to avoid denials: obtain PA where indicated, adhere to quantity limits, follow step-therapy sequences or request an exception, use mail-order or limited availability pharmacies when required, and supply specialty documentation for oncology/immunosuppressant therapies.
Obtain PA before dispensing drugs marked PA or B/D PA; absence of PA is a common denial trigger.
Check QL values on the Drug List (e.g., 28 per 28 days, 60 per 30 days, 180 per 30 days) and submit PA/exception to exceed limits.
For B/D PA drugs, include indication and site-of-care information to support Medicare Part B vs Part D determinations.
For antineoplastic/immunosuppressant agents include oncology specialty documentation and any required kit/titration regimen details (starter packs, dosing schedules).
If a drug is marked LA or limited availability, verify pharmacy network access or contact Member Services for routing.
When Step Therapy (ST) is required, document prior trials of required agents or request an exception with clinical rationale.
Use the Drug List index and formulation mapping to ensure prescriptions/claims match the table entry exactly (drug name, formulation, strength, and days' supply).

Prior Authorization
Prior Authorization and Quantity Limit Examples
Examples from the Drug List illustrating PA and QL controls — these examples are illustrative, not exhaustive. Always check the latest Drug List online for current flags and limits.
SOFOSBUVIR-VELPATASVIR (VOSEVI): PA; MO; QL (28 per 28 days); NDS.
Azithromycin inhalation/pack and certain formulations: entries showing PA; MO; LA; QL (84 per 56 days); NDS.
Amikacin injection solutions: examples list PA; MO for specific injectable formulations.
Many antineoplastic/immunosuppressant entries (e.g., BOSULIF, COMETRIQ, IMBRUVICA, IMFINZI) are marked PA or B/D PA and have QL and NDS controls.
IMBRUVICA oral capsules: PA; QL (30–120 per 30 days depending on strength); NDS — some strengths also B/D PA.
EMGALITY PEN and EMGALITY subcutaneous syringe: PA; MO; QL (2 per 30 days).
BELBUCA and other opioid formulations: PA; MO; QL (60 per 30 days) and NDS.
Diazepam oral solution and oral tablets: PA; MO; QL with some strengths also subject to ST.

Denial Risk
Denial Risk and Next Steps
If utilization-control requirements (PA, MO, QL, ST, LA, NDS, B/D PA) are not met, the Plan may deny coverage. Submit complete supporting documentation and use the appropriate request type (PA, exception, expedited exception) to reduce denial risk.
Missing PA, exceeding QL, or not meeting ST requirements are common denial triggers.
Include clinical rationale, prior therapy history, and prescriber statement when requesting exceptions.
For urgent clinical need, request an expedited exception and include the prescriber's supporting statement; turnaround is 24 hours when expedited.
Appeals process differs for ADD (Non‑Part D) drugs; see Member Services for appeals instructions.

Definitions and Terminology

Background: The Drug List groups drugs by medical condition and lists coverage rules, utilization controls (such as PA, MO, QL, NDS, LA), tier assignments, and quantity limits. It also explains how Drug List changes are handled (including immediate removal when required) and the processes for exceptions, transition supplies for new members, and appeals.

Drug List definition

Drug List (definition)Also called the List of Covered Drugs; lists prescription and over-the-counter drugs and items covered by HAP CareSource MI Health Link.

ContentThe Drug List shows tier, utilization controls, and any special restrictions for each listed product.

LocationReferenced throughout the policy tables and member handbook chapters.

Prior Authorization (PA)

Prior Authorization (PA)Permission from HAP CareSource MI Health Link before a drug can be dispensed and covered; absence of PA when required may result in noncoverage.

Where indicatedPA is shown in the 'Necessary Actions, Restrictions, or Limit On Use' column for specific formulations.

PurposeTriggers additional review and documentation for coverage decisions.

Step therapy

Step therapy (ST)Requirement to try drugs in a specified order for a medical condition before covering alternatives; exceptions can be requested with prescriber support.

IndicationST is denoted on the drug list where applicable (ST flag).

ExceptionPrescribers may request exceptions to bypass ST when clinically justified.

Generic drugs

Generic drugsGeneric drugs contain the same active ingredients as brand-name drugs, are FDA-approved, typically cost less, and may be substituted per state law.

CoverageHAP CareSource MI Health Link covers both brand-name and generic drugs.

SubstitutionPharmacy substitution may occur depending on state regulations.

Biosimilars / biological products

Biosimilars / biological productsBiological products are complex; biosimilars are similar alternatives and, if interchangeable under state law, may be substituted for the reference product.

Substitution rulesInterchangeability and substitution depend on state law.

NotificationThe plan may substitute new biosimilars/generics and will notify members/providers after changes.

OTC and non-drug OTC coverage

OTC coverageSome over-the-counter (OTC) drugs and certain non-drug OTC products are covered when prescribed by a provider and listed on the Drug List.

ExamplesCovered OTC items and non-drug OTC products are identified on the Drug List (e.g., vitamins, folic acid examples shown in member materials).

How to confirmMembers/providers should consult the Drug List to determine OTC coverage status.

PA (table abbreviation)

PA abbreviation in tablePA — Prior Authorization (administrative requirement indicated for some drugs in the table)

Table legendAbbreviations are defined at the beginning of the full formulary table (PA, MO, QL, NDS, etc.).

ImplicationPA shown next to a product requires prior approval before dispensing for coverage.

QL (Quantity Limit)

QL abbreviationQL — Quantity Limit: maximum units allowed in a specified period (e.g., per 28 or 30 days)

ExamplesQL examples in the table use formats like 'QL (20 per 30 days)' or 'QL (28 per 28 days)'.

EnforcementExceeding QL may trigger denial or require modification/PA per the policy.

MO (table abbreviation)

MO abbreviationMO — formulary action code used throughout the table (document excerpt does not fully define within these chunks)

UsageAppears with entries to indicate mail-order, medical override, or managed program flags depending on line context.

Refer to legendSee full table legend at the start of the Drug List for exact MO meaning per row.

NDS (table abbreviation)

NDS abbreviationNDS — New Drug Status / Non‑standard dosing or specialty distribution indicator as used in the table

ImplicationOften appears with QL/PA flags and may denote specialty distribution or retail limit (e.g., 30-day retail limit).

ReferenceSee entries where NDS accompanies MO/PA for product-specific notes.

Step Therapy Policies and Indicators

Step therapy requirement	Summary
Must try specified drugs in order unless exception granted
Step therapy may require members to try drugs in a specified sequence; prescribers may request an exception (for example if the first‑line drug 'doesn't work') per the plan's exception process

Step therapy requirement	Summary
Member must try preferred drug(s) per Step Therapy rules documented on the drug list
ST (Step Therapy) is indicated on the Drug List; the legend explains ST requires trying specified preferred drugs first before covering alternatives

Step therapy indicator	Summary / implication
LA or MO flags present on some entries
LA (Limited Access) or MO (Mail‑Order) may indicate restricted access or managed access pathways, but explicit step sequences are not provided in this excerpt

Product group	Step therapy / control note
Oral and inhaled antimicrobials
Many antimicrobial formulations show PA, MO or other controls in the Drug List; explicit step‑therapy sequences are not present in these chunks

Flag	Interpretation
LA or B/D flags
These flags may correspond to additional administrative or benefit/dispensing requirements (limited availability or B/D PA), but explicit multi‑step step‑therapy sequences are not provided in the excerpt

Flag	Meaning / effect
B/D PA
B/D PA entries indicate the drug may require Medicare Part B/Part D determination or additional billing/dispensing prior authorization controls

Flag	Program implication
B/D PA
B/D PA appears on some products and indicates additional benefit/department‑level prior authorization steps or specialty handling may be required

Flags	Implication
LA or NDS
LA (Limited Access) or NDS (limited to 30‑day supply / special distribution) indicate limited access pathways or special dosing/distribution; explicit step sequences are not provided in the excerpt

Product	Initiation regimen note
XCOPRI
XCOPRI is presented with titration packs/maintenance packs in the Drug List, implying an initiation/titration regimen though specific step‑therapy rules are not detailed here

Flags	Program control implication
MO or ADD
MO (Mail‑Order/managed) or ADD (additional documentation/non‑Part D) indicate program controls that may function like step or monitoring requirements; explicit step definitions are not included in the excerpt

Fragment content	Limitation
Utilization markers listed (PA, MO, LA, ST, QL, NDS etc.)
The fragment enumerates utilization control codes but does not define explicit step‑therapy sequences or required therapeutic failures for these agents within the provided excerpt

Product	ST presence
AUVELITY
AUVELITY is listed with ST (step therapy) and QL (60 per 30 days) indicating step therapy is required for coverage of AUVELITY in this excerpt

Product / formulation	Step therapy note
Diazepam oral solution / tablets
Some diazepam solution and tablet entries include ST (step therapy) in their 'Necessary Actions' field in the Drug List, indicating ST applies to those formulations

OpenPayer

List of Covered Drugs (Drug List) — Drug List Coverage Criteria

Coverage Criteria and Formulary Listings

Coding, Abbreviations and Quantity Examples

Provider Responsibilities and Utilization Controls

Definitions and Terminology

Step Therapy Policies and Indicators

Quantity Limit Examples by Product

Site of Care and Distribution Indicators

Biosimilars and Substitution Policy

Background and Scope