List of Covered Drugs (Drug List) — Formulary and Utilization Controls
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Describes the drugs, OTC items, and non-drug products covered by HAP CareSource MI Coordinated Health, including rules (prior authorization, quantity limits, step therapy) and how members/providers can request exceptions or find covered drugs.
No material clinical or coverage changes in this revision.
Coverage Criteria and Formulary Controls
General Coverage Conditions
Covered when ALL of the following are met:
From Drug List overview (B1).
Transition and Emergency Supplies
Temporary coverage / emergency supply permitted when standard coverage is not immediately available:
B9: temporary 30-day supply for first 90 days of membership.
B9 emergency/transition supply for LTC settings.
B9: multiple refills permitted to provide up to 30 days.
General coverage criteria
Covered when plan rules are satisfied and any listed requirements (PA/QL/ST/LA/MO/NDS) are met:
Overview and table legend (C, C1).
B12: exception decision timeframes and required prescriber statement.
C: MCD and appeals information.
Formulary coverage with line‑level utilization controls
Formulary coverage is indicated per drug line when ALL of the following apply:
Per‑line usage controls and QL shown on formulary rows.
IV/recon solutions and inhaled antibiotics examples (meropenem, tobramycin, vancomycin).
General coverage with utilization controls
Coverage is governed per drug when utilization controls are met:
Examples: abiraterone QL 120 per 30 days (250 mg) and B/D PA/Bortezomib lines.
See table legend and per‑product 'Necessary actions' column.
General coverage constraints
Coverage for listed antineoplastic/immunosuppressant drugs is subject to the following documented utilization controls where specified:
Multiple oncology/immunosuppressant entries show PA/B/D PA (chunks 144–156).
Examples: ODOMZO QL 30 per 30 days; PIQRAY QL 28 per 28 days; Rozlytrek QL variants.
Per‑line 'Necessary Actions' column provides flags and instructions.
Covered with utilization controls
Coverage for the listed drugs is subject to the following controls as shown per product entry:
Per‑product 'Necessary Actions, Restrictions, or Limit On Use' column governs coverage.
Denial risk described in multiple sections; providers should obtain PA and follow documentation instructions.
Drugs listed on the Drug List may be changed at any time consistent with Medicare and Michigan Medicaid rules. In particular, the plan may add or remove drugs, or change utilization controls such as requiring or removing prior authorization (PA), modifying quantity limits (QL), or adding/removing step therapy (ST). The plan may immediately substitute an interchangeable biosimilar for an original biological product without requiring a new prescription.
Drugs that are not on the Drug List may not be covered unless an exception is granted. Some drugs marked MCD are not Part D drugs and follow different rules for coverage, appeals, and grievances; providers and members should follow the special appeal processes for non‑Part D items.
The formulary table uses symbols and abbreviations to indicate utilization controls for each drug line. Providers should consult the table legend at the beginning of the full Drug List for definitions of codes such as PA, QL, MO, LA, NDS, and B/D PA when preparing authorization requests or claims.
This section does not list explicit exclusions. Coverage is shown per drug line and governed by the listed utilization controls (for example, many IV and specialty products are shown with PA, MO, QL, or NDS flags). Where a control is present on the drug row, fulfillment of that control is required for benefit processing.
No specific exclusion conditions or clinical-necessity criteria are contained in this extract of the Drug List. Individual drug rows indicate utilization controls; full clinical eligibility criteria, if any, are located elsewhere in policy or supporting authorization guidelines.
The partial extract does not list explicit exclusions. Instead, many antineoplastic and immunosuppressant entries are shown with utilization controls (for example B/D PA, PA, MO, QL, LA, NDS) that govern coverage and may require prior review or documentation.
This extract does not contain indication‑level medical necessity criteria. Coverage for the drugs shown is conditional on meeting the per‑line utilization controls indicated (e.g., PA, QL, MO, LA, NDS); providers should submit the documentation specified by those controls as part of authorization requests.
No explicit exclusions are listed in the presented chunks. The table uses line‑level annotations to denote required actions and restrictions rather than listing standalone exclusion rules in this segment.
The extract does not include comprehensive medical‑necessity criteria or exclusion conditions. The Drug List rows refer to utilization controls (PA, MO, QL, NDS, B/D PA) that must be satisfied for coverage; for full clinical criteria and exclusion rules, refer to the complete policy and the table legend at the start of the Drug List.
If a required prior authorization is not approved or if stated utilization requirements are not met, the plan may deny coverage for the drug. Providers should secure approvals before dispensing when a drug row indicates PA or other mandatory controls.
Not applicable in this excerpt: no additional 'not medically necessary' statements are shown here. The Drug List primarily denotes per‑product utilization controls rather than explicit 'not medically necessary' determinations in these chunks.
This extract does not include explicit 'not medically necessary' determinations. Coverage decisions reflected here are governed by the per‑line codes and any required authorization processes; for NMP determinations see the full policy documentation.
Prior authorization required — coverage may be denied without PA
HAP CareSource MI Coordinated Health may not cover the drug if you do not obtain prior authorization when it is required by the Drug List; obtain approval from the plan before dispensing to avoid denial of coverage.
- Prior authorization (PA) is required where 'PA' or 'B/D PA' is shown on a drug line; providers must submit PA requests per the plan's process before filling.
- Failure to get PA when required may result in the plan not covering the drug or claim denial.
Provider Actions, Prior Authorization, and Documentation
Prior authorization required for some drugs
Prior authorization is required for some drugs listed on the Drug List; you or the prescriber must get approval from HAP CareSource MI Coordinated Health before filling prescriptions for drugs indicated as PA.
- Check the 'Necessary actions, restrictions, or limits on use' column on the drug table (pages 15–116) for PA flags.
- If PA is indicated and not obtained, the plan may not cover the drug.
Obtain prior authorization before filling
When a drug line shows 'PA' (or 'B/D PA'), prior authorization must be obtained from the plan before the prescription is filled to secure coverage.
- Obtain approval prior to dispensing for any product line marked PA or B/D PA.
- Follow the plan's PA submission process (see table header/legend for guidance).
PA examples in the formulary
Examples of drugs in this excerpt that are marked with PA include LEDIPASVIR‑SOFOSBUVIR (PA; QL 28 per 28 days), MAVYRET (PA; QL 84 or 168 per 28 days depending on formulation), LIVTENCITY (PA; LA; QL 120 per 30 days), and SOFOSBUVIR‑VELPATASVIR (PA; QL 28 per 28 days).
- Review the specific product row for exact PA and QL values before submitting a request.
PA required for many antiinfectives (IV/specialty)
Many intravenous and specialty antiinfective products in the antiinfectives section are listed with 'PA' indicating prior authorization is required for coverage.
- Examples include cefoxitin and ceftazidime IV entries showing PA.
- Confirm PA requirements on the IV product row before dispensing.
PA required for many agents
Numerous intravenous and oral agents in the formulary display 'PA' on their drug lines; providers must obtain prior authorization when PA is indicated to secure coverage.
- Check each drug row for the 'Necessary actions, restrictions, or limit on use' field for PA flags and any accompanying QL values.
Obtain PA and respect Quantity Limits (QL)
Many drugs require both prior authorization (PA) and have specified quantity limits (QL); obtain PA and ensure the requested quantity does not exceed the listed QL (e.g., abiraterone 250 mg QL 120 per 30 days).
- Verify and document the per-drug QL shown on the formulary row when submitting PA.
- Requests exceeding the QL may be denied or require override.
PA required for many antineoplastic/immunosuppressants
Numerous antineoplastic and immunosuppressant products are marked with PA or B/D PA and often include additional program flags (MO, LA, NDS); obtain the required prior authorization and follow specialty program instructions before dispensing.
- When B/D PA appears, provide setting/use details as required to determine Part B vs Part D coverage.
- Follow any MO/LA/NDS instructions listed on the product row.
PA plus additional utilization controls for specialty agents
Prior authorization and other utilization controls (MO, LA, NDS) are applied to many antineoplastic/immunosuppressant drugs; providers must obtain PA and meet any additional listed requirements prior to coverage.
- Confirm PA, MO, LA, QL, and NDS flags on each product row and submit supporting documentation as indicated.
Follow per-product PA indications
Prior authorization is frequently indicated in the 'Necessary actions, restrictions, or limit on use' column; obtain PA where shown to avoid claim denials.
- Follow the per-product PA requirement noted in the formulary table.
- Provide required documentation and program codes (e.g., NDS, MO) with the PA request.
PA noted in product entries (example: AIMOVIG)
Many formulary entries indicate PA in the 'Necessary actions, restrictions, or limit on use' column (examples include AIMOVIG AUTOINJECTOR listed as PA; QL 1 per 30 days); obtain PA for these products before dispensing.
- Check the specific QL values (e.g., AIMOVIG QL 1/30 days) when requesting authorization.
- Submit PA per the plan's process to secure coverage.
Prior authorization indicated in many product rows
The table includes many PA flags; providers must obtain prior authorization for listed PA drugs to avoid noncoverage.
- When PA appears alongside other flags (MO, NDS, LA), include supporting documentation as required.
- If unsure, consult the table legend at the start of the drug tables for definitions and submission guidance.
PA required — review each drug row
Several drugs in the list are explicitly marked 'PA' and will require prior authorization before the plan will cover them; review the drug's formulary row and obtain PA accordingly.
- Examples in the excerpt include lorazepam formulations and lurasidone entries showing PA alongside QL values.
- Failure to obtain PA when required may result in denial.
PA and documentation required for PA requests
Prior authorization is required for listed PA drugs; obtain PA and include any required documentation (NDS, MO) when submitting an exception or authorization request.
- The drug table's 'Necessary actions' column shows PA, ST, QL, NDS — follow those requirements when requesting coverage.
- If an exception is needed, a prescriber's supporting statement is required; expedited exceptions require prescriber support for a 24‑hour decision.
Step therapy must be met when ST is shown
Drugs marked 'PA' in the formulary may also have a 'ST' (Step Therapy) indicator; members must meet step therapy requirements (try specified first-line drugs) before the plan will cover alternatives unless an exception is granted.
- Refer to the product row for ST flags and to the plan's step therapy documentation for required sequences.
- Providers can request an exception with prescriber support if step therapy would harm the member.
Consult step therapy documentation for sequences
Step therapy is referenced in the table legend and on some product rows, but explicit step sequences are not provided in this excerpt; consult the formulary header or the plan's step therapy documents for the required sequences.
- If ST appears on a product row (e.g., EXXUA, OPIPZA), follow the plan's documented step sequence or submit an exception with prescriber justification.
Step therapy indicators present — get details from legend
Some products include ST with other management flags (MO, NDS, QL), but explicit step-by-step sequences are not shown here; check the full table header/legend and plan materials for the detailed ST algorithm.
- When ST is present (examples: EXXUA XR, OPIPZA oral film), ensure prior steps are documented before requesting coverage for subsequent agents.
Limited access / specialty routing for select agents
Some agents have LA (limited access), MO, or NDS designations suggesting limited distribution or specialty routing; follow listed site/program instructions and any PA or specialty pharmacy requirements on the product row.
- Examples: ARIKAYCE shows PA; LA; NDS.
- Contact Customer Service if the product's LA designates limited pharmacy availability.
Specialty drugs may need B/D PA or specialty review
Certain antineoplastic/immunosuppressant agents are marked with 'B/D PA' or other specialty flags indicating they may require benefit/designation review or specialty prior review; follow the payer's specialty drug processes when submitting requests.
- B/D PA may require submission of site/use details to determine Part B vs Part D coverage.
- Include program flags (MO, LA, NDS) and QL information in the authorization request.
Follow site/limit codes (LA, MO, NDS) on drug rows
Some entries include site/limit codes like LA, MO, and NDS which reflect utilization management and potential site-of-care or distribution restrictions; providers should follow the listed site codes and program instructions when rendering or billing.
- Check the product row for LA or MO to determine if limited pharmacies or medical oncology settings are required.
- Provide site-of-care information when B/D PA is indicated.
Step therapy sequences not detailed here — consult policy
The excerpt does not list step-therapy sequences in detail; where ST appears you must follow the plan's step therapy rules as documented in the formulary header or step therapy policy.
- If ST is required, document previous drug trials or submit an exception supported by the prescriber.
B/D PA flags require specialty/benefit details
Some entries indicate 'B/D PA' which may denote specialty or benefit/designation prior authorization; explicit step-therapy algorithms are not provided in this excerpt — obtain B/D PA and follow specialty submission requirements when shown.
- Provide the necessary clinical use and setting information when B/D PA appears on the product row.
MO/LA indicators require extra steps/documentation
Entries with 'MO' or 'LA' signal management actions that may require additional documentation or site-specific handling; providers must follow those listed controls when requesting coverage.
- Include documentation for MO (medical override) requests and follow LA routing for limited access products.
Step therapy required for specific products
Some products (e.g., EXXUA XR, OPIPZA oral film) explicitly list Step Therapy (ST) and must meet step therapy requirements before coverage is approved; follow the ST flag on the product row and submit documentation of prior therapy or an exception request.
- Document prior drugs tried and outcomes when submitting a PA or exception for ST products.
- If requesting an exception, include prescriber supporting statement per plan timelines.
Prescriber support required for exceptions (standard and expedited)
A prescriber's supporting statement is required to process an exception request; expedited exception requests require the prescriber's support to receive a decision within 24 hours.
- Standard exception decisions: 72 hours after receipt of prescriber statement.
- Expedited exception decisions: 24 hours with prescriber support.
NDS entries require additional documentation
Several products are marked with NDS indicating additional documentation or limited distribution status is required for coverage decisions; include required documentation (NDS notes) with PA or exception submissions.
- Check product rows for NDS alongside PA/MO/QL and attach supporting clinical documentation when submitting PA.
Document QL and distribution status on requests
Quantity limits (QL) and specialized distribution statuses (NDS, LA) are shown for many products; document the requested quantity and distribution status on PA requests and ensure the requested amount does not exceed the listed QL.
- Examples: azithromycin inhalation QL 84 per 56 days; meropenem IV recon soln QL 30 per 10 days.
- Requests exceeding QL may be denied or require override.
Follow PA/MO/QL/NDS processes when submitting requests
Prior authorization and quantity limit indicators (PA, QL, MO, NDS) are shown on each drug entry; providers must follow the payer's PA and documentation process where those codes are indicated.
- Consult the table header/legend for definitions of PA, QL, MO, NDS and include required supporting information with PA submissions.
Include NDS/MO annotations and supporting docs with PA
Entries frequently include PA with NDS or MO annotations indicating documentation or specialty distribution requirements must be met for coverage; include those annotations and supporting documentation when requesting authorization.
- If NDS or MO is listed, provide the specialty pharmacy or medical site details and clinical justification as requested.
Consult formulary table legend for abbreviations and rules
The table uses abbreviations (PA, B/D PA, MO, LA, NDS, QL); consult the table legend at the beginning of the drug tables for exact definitions and submission guidance before preparing an authorization request.
- Refer to the table header/legend (page 13 onward) for symbol meanings and submission instructions.
Provide required documentation for utilization controls
Providers must follow documented utilization controls (PA, MO, LA, QL) and supply supporting documentation per the plan's guidance when seeking coverage for managed products.
- Where PA is shown, submit clinical justification and any required supporting records.
- For LA or MO products, follow program-specific routing and documentation instructions.
Denial risk if PA/QL/MO/NDS/ST requirements are unmet
If prior authorization is not approved or requirements (PA, QL, MO, NDS, ST) are not met, the plan may deny coverage for the drug.
- Confirm PA approval and that requested quantities meet QL before dispensing to reduce denial risk.
- Document exceptions or overrides with prescriber support when appropriate.
PA absence or QL exceedance may trigger denial
Absence of required prior authorization (PA) or exceeding specified quantity limits (QL) are explicit denial triggers; obtain PA and adhere to QL values noted on the product row to avoid denials.
- Examples of QLs that may trigger denial if exceeded include 30/30, 60/30, 120/30, 324/30 depending on product.
- When in doubt, obtain PA and document justification for higher quantities.
Denial risk for specialty agents without PA/B/D PA
Claims for listed antineoplastic/immunosuppressant drugs may be denied if prior authorization (PA) or benefit/designation (B/D PA) requirements are not satisfied; providers should obtain required approvals before administering or dispensing these agents.
- B/D PA entries commonly require additional submission details to determine coverage under Part B vs Part D.
- Include NDS/MO/LA flags and relevant clinical documentation with PA submissions.
Denial triggers from utilization controls (PA/MO/QL/NDS)
Prescriptions exceeding listed quantity limits (QL) or lacking required prior authorization (PA), medical override (MO), provider attestation (LA), or required documentation (NDS) may be denied; verify the drug row and submit necessary approvals/documentation before billing.
- Review QL values on the product row and include prescriber attestation or MO requests where applicable.
- If PA is required, secure authorization prior to dispensing to avoid claim denial.
Drug List Codes, Utilization Codes, and Quantity Limits
| MCD | Non-Part D drugs or OTC items that are covered by Medicaid only |
| B/D PA | Drug may be covered under Medicare Part B or D depending on circumstances; additional information may be required |
| LA | Limited availability; may be available only at certain pharmacies |
| MO | Mail-Order Drug available through mail-order service and retail network |
| NDS | Non-Extended Days' Supply — limited to 30 days' supply at retail or mail-order |
| PA | Prior Authorization required |
| QL | Quantity Limit — plan limits the amount covered |
| ST | Step Therapy — must try specified drugs first |
| V | Vaccine provided at no cost when used per CDC/ACIP recommendations |
| QL (120 per 30 days) | Quantity limit for abiraterone oral tablet 250 mg |
| QL (60 per 30 days) | Quantity limit for abiraterone oral tablet 500 mg |
| B/D PA | Benefit/Design PA designation present for multiple agents (e.g., ADCETRIS, BORTEZOMIB) |
| PA | Prior Authorization |
| LA | Site/limit code (appears with certain agents) |
| MO | Site/limit or program code (mail-order/medical override) |
| NDS | Notation present in table (legend referenced elsewhere) |
Per-Product Quantity Limit Examples
Step Therapy Requirements
| Step therapy summary | Policy detail |
|---|---|
| Member must try specified initial drugs before coverage of subsequent drugs unless an exception is granted | Step therapy means trying drugs in a specified order for a condition; if the prescriber documents the first drug did not work or was not tolerated, the next drug will be covered. Members may request an exception per plan procedures. |
| ST application | Source / notes |
|---|---|
| Plan may require trying specified first-line drugs before covering alternatives for the condition (ST). | C1 table legend: 'ST: Step Therapy' — the Plan requires trying certain drugs first before covering others for the same condition; see drug tables for per‑product ST notation. |
| Managed-access indicators | Implication |
|---|---|
| MO and NDS labels appear on multiple antiretroviral and antiviral products indicating managed access | Entries for itraconazole, ketoconazole, APTIVUS and others show 'MO' and some include 'NDS', signaling medical-override or documentation/special distribution requirements; explicit ST sequences are not provided in these lines. |
| Antibiotics with controls | Requirements shown |
|---|---|
| Some oral and inhaled antibiotics have MO and PA indicators and require prior authorization before coverage. | Azithromycin entries include MO, PA, LA, QL (84 per 56 days) and NDS in various formulations; other inhaled antibiotics (e.g., TOBI, tobramycin) are shown with QL and PA/ MO flags elsewhere. |
| Antineoplastic step controls | Example controls noted |
|---|---|
| Some antineoplastic agents require B/D PA or specialty review before coverage | Multiple antineoplastic entries show 'B/D PA', 'PA', 'MO', 'NDS' and QL (e.g., BORTEZOMIB lines: B/D PA; NDS; or PA; LA; QL (30 per 30 days); KEYTRUDA: PA; MO; NDS; KEYTRUDA also shows PA; LA; QL (60 per 30 days)). |
| Explicit ST sequences | What is present in excerpt |
|---|---|
| No explicit step-therapy sequences provided in these chunks | The excerpt predominantly lists per-product utilization controls (PA, QL, LA, MO, NDS) and does not set out multi-step sequences or algorithmic ST pathways in the shown lines. |
| PA / program flags | Step therapy specifics |
|---|---|
| PA and program flags (MO, LA) are noted for many agents | Many entries include PA and modifiers such as MO or LA indicating medical-override or limited access; the document notes these flags but does not list step therapy sequences in this section. |
| ST sequences shown? | Primary controls present |
|---|---|
| No explicit step therapy sequences shown — PA and QL predominate | KEYTRUDA and other antineoplastic entries illustrate PA, LA, QL and NDS usage; the excerpts emphasize authorization and quantity limits rather than step algorithms. |
| PA and QL predominance | Notes |
|---|---|
| PA and B/D PA indicated for many products; prior authorization required before coverage | Doxorubicin and multiple antineoplastic lines show 'B/D PA' or 'B/D PA; MO; NDS'; SCEMBLIX shows PA; QL (120 per 30 days); NDS — demonstrating PA/QL as primary utilization controls. |
| First-line controls | Detail |
|---|---|
| PA and other management codes applied as first-line controls | Antineoplastic/immunosuppressant entries frequently list PA, MO, LA, NDS and quantity limits (examples shown across the table); where PA is present it functions as a first-line requirement for coverage. |
| Starter kits / managed initiation | Requirements |
|---|---|
| Starter kits/packs indicate managed initiation with PA/LA and QL requirements | ZEPOSIA STARTER KIT and STARTER PACK entries show PA; MO; QL (28 per 180 days) and PA; MO; LA; NDS on some starter kit lines, indicating managed initiation and additional authorization/documentation requirements. |
| Explicit ST sequences present? | Excerpt conclusion |
|---|---|
| No step therapy sequences specified in this excerpt | The provided lines focus on per-product controls (MO, PA, QL, NDS) without giving step-by-step ST algorithms in the excerpted content. |
| Products with ST noted | Examples / requirement |
|---|---|
| Step therapy applies to specified products (examples: EXXUA XR, OPIPZA oral film, some paliperidone entries) | EXXUA ORAL TABLET EXTENDED RELEASE shows 'ST; MO; QL (30 per 30 days); NDS'. OPIPZA oral film lines include 'ST; MO; QL (30–180 per 30 days); NDS'. Paliperidone extended-release entries list ST notation on some lines — when ST is present the member must meet the step requirement before coverage is approved. |
Site of Care and Administration Notes
B/D PA may affect Part B vs Part D coverage
Some drugs listed may be covered under Part B or Part D depending on the setting and use (B/D PA); when B/D PA appears, provide setting and use details with the PA to determine appropriate billing and coverage.
- Examples: many antineoplastic IV products show B/D PA — supply clinical and site-of-care information with the authorization request.
IV/infusion products often require PA and site‑of‑care handling
Intravenous formulations and infusion products imply administration in infusion centers or hospital outpatient/office settings and often require PA and QL; follow site-of-care requirements and obtain PA before scheduling administration or billing.
- Meropenem IV recon soln shows PA; QL (30 per 10 days) — secure PA before infusion.
- Follow any LA/MO/NDS routing noted on the IV product row.
Definitions and Abbreviations
Background and Policy Scope
The Drug List background explains drug categories and substitution rules. It defines generic drugs and states that interchangeable biosimilars may be substituted for original biological products in accordance with state law; it also distinguishes over‑the‑counter items and provides context for tiering and formulary updates.
Biosimilars and Interchangeable Products
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.