List of Covered Drugs (Drug List) — CareSource MyCare Ohio
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CareSource MyCare Ohio formulary describing covered drugs, utilization controls (prior authorization, quantity limits, step therapy), and member/provider processes for exceptions and temporary supplies.
No material clinical or coverage changes in this revision.
Coverage Criteria and General Rules
General coverage conditions
Covered when ALL of the following are met
From Drug List coverage rules
From Drug List coverage rules
From Drug List coverage rules
Temporary and transition coverage
Temporary/transition supplies covered in specific scenarios
From B9
From B9
From B9
Temporary Supply Coverage
Temporary supply coverage rules
From B9
From B9
Exception Process and Timelines
Exception request and decision timelines
From B10 and B11
From B12
Formulary Structure and Coverage
Formulary coverage and tiers
From B19
From C1
Coverage conditioned on listed requirements
Coverage and utilization management for listed drugs are governed by the Requirements/Limits column; coverage is conditional on meeting those controls
From formulary 'Requirements / Limits' definitions and antineoplastic/immunosuppressant entries
Drugs that are removed from the market or determined to be unsafe may be taken off the CareSource MyCare Ohio Drug List immediately and will not be covered.
When a formulary entry lists PA (Prior Authorization), the plan requires approval before the prescription can be filled; if prior authorization is not obtained, CareSource MyCare Ohio may not cover the drug.
Within the excerpted formulary segments provided here there are no standalone explicit exclusion statements; the drug listings instead use requirement and limits codes (e.g., PA, QL, MO, NDS, LA, B/D) and refer readers to the table legend at the start of the full Drug List for symbol meanings that may imply coverage constraints.
The partial drug table shown in this excerpt does not include explicit exclusion conditions for specific products; coverage language is conveyed via the Requirements/Limits column entries rather than separate exclusion statements in these chunks.
This segment of the Drug List does not list explicit exclusions; instead, the table uses symbols and abbreviations in the Requirements/Limits column. Users should consult the formulary legend at the beginning of the full table to interpret symbol meanings that drive coverage decisions.
The provided extract includes many requirement flags (e.g., PA, MO, QL, NDS, LA, B/D) and quantity limits but does not contain standalone exclusion language; coverage conditions for each line are determined by the Requirements/Limits entries and the table legend.
CareSource MyCare Ohio will cover drugs listed on the Drug List when the prescriber determines the drug is medically necessary, CareSource MyCare Ohio agrees the drug is medically necessary, and the prescription is filled at a CareSource MyCare Ohio network pharmacy.
No explicit 'Not Medically Necessary' (NMN) statements appear in the excerpted sections; coverage determinations in this extract are expressed through the Drug List entries and the Requirements/Limits codes rather than by separate NMN declarations.
This partial section does not include explicit statements labeling drugs as 'Not Medically Necessary.' Instead, access is controlled through the Requirements/Limits codes (e.g., PA, MO, QL, NDS) applied to individual formulary entries.
Within the provided excerpt there are no line‑level declarations that a drug is 'not medically necessary.' The plan communicates coverage conditions via the Drug List and the associated requirement/limit codes; for full NMN determinations refer to the complete policy and PA criteria.
Provider Responsibilities, Prior Authorization, and Documentation
Prior Authorization Required
Prior authorization required — Some drugs listed on this Drug List require prior authorization (PA) from CareSource MyCare Ohio before the prescription can be filled. If prior authorization is not obtained when required, the Plan may not cover the drug and the claim may be denied.
- PA = Prior Authorization — approval required before dispensing
- Many antineoplastic and immunosuppressant drugs and select high-tier or specialty products frequently require PA or B/D PA (benefit/setting determination) as shown in the Requirements/Limits column
Prior authorization and requirement codes
Prior authorization and requirement codes — The formulary uses requirement codes in the 'Requirements/Limits' column that may affect coverage. These include PA (Prior Authorization), B/D PA (may be covered under Medicare Part B or D depending on use/setting), MO (Mail-Order availability), LA (Limited Availability), QL (Quantity Limit), NDS (Non‑Extended Days' Supply), and ST (Step Therapy). Failure to meet the indicated requirement(s) may result in denial or reduced coverage.
- B/D PA: may require documentation to determine Part B vs Part D coverage
- MO: mail-order designation — may be required or preferred for maintenance meds
- LA: limited to certain pharmacies; call Customer Service for details
- QL and NDS: quantity and days' supply limits applied as indicated
- ST: step therapy — prescriber must try required agent(s) first
Prior authorization required for many listed drugs
Prior authorization required for many listed drugs — Numerous drugs across therapeutic categories (including many antineoplastic and immunosuppressant agents, specialty drugs, and certain formulations) list PA, B/D PA, or other requirement codes in the Requirements/Limits column. Examples include oral, IV, and injectable formulations where PA and site/setting documentation is commonly required.
- Many entries include PA or B/D PA and may also carry MO, LA, QL, NDS, or ST flags
- Site-of-care or formulation-specific PA may apply (e.g., certain IV or infusion products)
Prior authorization and requirement summary
Prior authorization and requirement summary — To receive coverage, providers must follow the Requirements/Limits for each formulary entry. Requirements may include submitting clinical documentation, fulfilling step therapy, adhering to quantity limits, or confirming the benefit/setting. Requests that require B/D PA need supporting documentation describing use and setting to determine Part B vs Part D coverage.
- Follow the exact codes shown in the 'Requirements/Limits' column for each drug
- B/D PA entries generally require additional clinical documentation to determine coverage pathway
PA required for specific formulations
PA required for specific formulations — Some formulations (for example, certain intravenous, injectable, or high-cost specialty formulations) specifically include 'PA' or 'B/D PA' in their Requirements/Limits. Check the formulation-level line in the table for PA, MO, LA, QL, or NDS flags before dispensing.
- Formulation-specific entries may carry different requirements than other formulations of the same active ingredient
- If Requirements/Limits lists PA for a given formulation, obtain PA prior to dispensing
Prior authorization required where noted
Prior authorization required where noted — Certain products and dose forms list 'PA' in the Requirements/Limits (for example, many oncology, infusion, and specialty products). Claims for these items may be denied if PA or B/D PA (when applicable) is not obtained.
- Examples across therapeutic classes — review the Requirements/Limits column on the drug line
- Denial is possible if PA or B/D PA is not in place
Prior Authorization Denial Risk
Prior Authorization Denial Risk — Failure to obtain required prior authorization, to satisfy step therapy (ST), to comply with quantity limits (QL/NDS), or to submit required B/D PA documentation may result in claim denial or noncoverage.
- PA, B/D PA, ST, MO, LA, QL, and NDS are actionable requirements — not meeting them can trigger denial
- For B/D PA, lack of setting/use documentation may prevent correct Part B vs Part D adjudication
Requirement codes may trigger denial or restriction
Requirement codes may trigger denial or restriction — The codes shown in the Requirements/Limits column indicate utilization management controls that must be satisfied for coverage. Examples include PA (prior authorization), ST (step therapy), QL (quantity limits), NDS (non‑extended days' supply), MO (mail-order), LA (limited availability), and B/D PA (benefit/setting review).
- Claims not meeting the listed Requirements/Limits may be denied or require additional follow-up
- Consult the specific drug line to determine which controls apply
Member document access and Exception Supporting Statement
Member document access and exception support — Members may request this Drug List or other plan documents in alternate formats (large print, braille, audio) or other languages by calling Member Services. For exception requests that need prescriber supporting statements, fax the prescriber's statement to the number provided.
- Member Services: 1-855-475-3163 (TTY: 1-833-711-4711 or 711), Mon–Fri 8 a.m.–8 p.m. ET (extended availability Oct 1–Mar 31)
- Exception prescriber supporting statement fax: 1-877-328-9660 — standard decision within 72 hours; expedited within 24 hours if prescriber certifies harm from delay
Definitions and support contact; Submission guidance
Definitions, provider support contact, and submission guidance — The formulary defines the codes and abbreviations at the start of the drug table. Providers should consult that legend and follow the Requirements/Limits when submitting authorization requests. Documentation requirements vary by requirement code (B/D PA often requires setting/use documentation; PA may require clinical justification).
- Consult the formulary legend for meanings of PA, B/D PA, MO, LA, QL, NDS, ST
- Submit required clinical documentation as specified for B/D PA or PA requests
- For questions or to submit requests, call CareSource MyCare Ohio Provider Services at 1-855-475-3163 (TTY details as above)
Step therapy / specialty requirements
Step therapy and specialty requirements — Some drugs are subject to step therapy (ST) or other program-specific requirements. When ST applies, required prior agents must be tried and documented before the requested drug will be covered. Certain specialty products may carry LA, MO, or B/D PA flags reflecting benefit, site, or distribution controls.
- ST indicates a required trial of specified agents before coverage of an alternative
- Temporary 30‑day supply may be available for new members during transition (chunk 18)
- LA and MO flags indicate limited pharmacy availability or mail‑order pathways for specialty agents
Formulary Codes, Requirement Flags, and Quantity Limit Examples
| AIMOVIG | AIMOVIG AUTOINJECTOR — Requirements /Limits = PA; MO; QL (1 per 30 days). |
| EMGALITY | EMGALITY PEN / SUBCUTANEOUS SYRINGE 120 — Requirements /Limits = PA; MO; QL (2 per 30 days). |
| XCOPRI | XCOPRI TITRATION PACK / ORAL TABLETS — referenced as drug name for topiramate products; QL (28 per 180 days) for some formulations. |
| VALTOCO | VALTOCO — Requirements /Limits = PA; MO; QL (10 per 30 days). |
| INBRIJA | INBRIJA — referenced in antineoplastic/neurology lists (ensure present in formulary mapping). |
| NEUPRO | NEUPRO — referenced in neurology / movement disorder product group; ensure availability and any QL or MO flags. |
| QL_120_30 | Example: QL (120 per 30 days) — e.g., itraconazole, famciclovir, EVOTAZ/ETRAVIRINE entries. |
| QL_28_28 | Example: QL (28 per 28 days) — e.g., some PAXLOVID/SOFOSBUVIR/VALTOCO related entries. |
| QL_84_28 | Example: QL (84 per 28 days) — e.g., MAVYRET oral tablet. |
| QL_4000_10 | Example: QL (4000 per 10 days) — vancomycin IV piggyback examples. |
| QL_40_10 | Example: QL (40 per 10 days) — vancomycin oral capsule. |
| QL_240_30 | Example: QL (240 per 30 days) — AUGTYRO. |
| QL_66_28 | Example: QL (66 per 28 days) — AVMAPKI-FAKZYNJA. |
| QL_30_30 | Example: QL (30 per 30 days) — many oncology oral products. |
| QL_180_30 | Example: QL (180 per 30 days) — multiple antineoplastics (e.g., abiraterone). |
| QL_60_30 | Example: QL (60 per 30 days) — various products. |
| PA | Prior Authorization required for listed products (PA). |
| MO | Mail-Order availability flag (MO). |
| LA | Limited Availability (LA) — specialty or limited pharmacies. |
| NDS | Non-Extended Days' Supply (NDS) — limited to 30-day supply at retail/mail-order. |
| B/D PA | May require Part B vs Part D determination (B/D PA). |
Step Therapy Rules and Indicators
| Requirement | Summary / Plan action |
|---|---|
| Step therapy (ST) | Members must try specified prior agent(s) before the plan will cover a next‑line drug; prescriber may document failure or contraindication to the prior agent to allow coverage of the alternative. |
| Temporary supply during step review | Drugs subject to step therapy may be eligible for a temporary 30‑day supply for new members while exception or transition requests are processed. |
| Step Therapy Indicator | Meaning / Plan action |
|---|---|
| ST (Step Therapy) | Plan requires specified first‑line drugs to be tried for the medical condition before covering alternative drugs; if first drug fails or is not tolerated, second drug may be covered upon documentation. |
| Table legend reference | See the formulary table legend at the beginning for specific drug‑level step therapy details and required sequence; providers may call Member Services for clarification. |
| Flags present | Interpretation |
|---|---|
| PA; MO; LA | Entries showing combinations such as PA; MO; LA indicate prior authorization and management/limited‑access routing may apply and can reflect step or specialty requirements; specific step algorithms are not provided in these excerpts. |
| NDS | Non‑drug‑specific (NDS) appears alongside other flags and may affect how step/management rules are applied per the formulary legend. |
| Agent / Flag examples | Implication for step or authorization |
|---|---|
| ADCETRIS; many antineoplastic agents (e.g., ALECENSA, azacitidine) | Marked B/D PA; MO; NDS or PA; LA indicating layered authorization (benefit/diagnosis PA, medical override, limited access) — may require multiple authorization pathways before coverage. |
| AUGTYRO; AYVAKIT; BALVERSA | Examples show PA with LA or B/D PA flags — plan applies prior authorization and may route approvals through specialty/benefit review consistent with step/managed processes. |
| Flags | Practical effect |
|---|---|
| MO; LA | MO (medical/management override) and LA (limited access) flags indicate utilization management or step‑edit controls may apply to the listed product; exact step criteria are defined in the full formulary legend or PA criteria. |
| B/D PA | B/D PA denotes benefit/diagnosis or billing/documentation prior authorization which may functionally operate like a step/managed edit for coverage determinations. |
| Drug | Step-like controls / Limits |
|---|---|
| AIMOVIG (autoinjector) | Requirements/Limits = PA; MO; QL (1 per 30 days) — prior authorization plus a quantity limit of 1 per 30 days restricts access and functions similarly to step management. |
| Product / Entry | Step Therapy note |
|---|---|
| EXXUA (extended release formulations) | Requirements/Limits include ST and QL (e.g., ST; QL (30 per 30 days)) indicating step therapy is required for specific formulations. |
| FANAPT titration packs | Entries list ST; MO; QL (varies) for FANAPT titration packs — step therapy applies to these formulations per the Requirements/Limits column. |
| Product | ST flag |
|---|---|
| RALDESY | Requirements/Limits = ST; MO; NDS — 'ST' present indicates step therapy applies to RALDESY per the formulary entry. |
| General observation | Supporting detail |
|---|---|
| Step therapy not fully enumerated | This segment does not provide full step therapy algorithms for most agents; several agents are listed with PA requirements indicating prior authorization is required before coverage. |
| Flag examples | Possible meaning re: step edits |
|---|---|
| B/D PA | Benefit/diagnosis or billing/documentation PA entries (B/D PA) may reflect step therapy or benefit‑based edits requiring additional review prior to coverage. |
| Managed (MO) entries | MO combined with PA/QL flags indicates utilization management; when present these may function as step‑like edits though specific sequences are not shown here. |
| Requirement / Flag | Operational effect (provider action) |
|---|---|
| PA (Prior Authorization) | Many listed products require prior authorization before the prescription will be covered; failure to obtain PA may result in noncoverage — follow the Requirements/Limits field for each product and submit supporting documentation as required. |
| QL (Quantity Limit) / NDC restrictions | Adhere to quantity limits (QL) shown per time period and any NDC‑specific restrictions noted (e.g., 'ONLY NDCS STARTING WITH ...'); claims exceeding QL or using non‑allowed NDCs may be denied or require override. |
| ST / MO / LA / B/D PA | Step therapy (ST) and management flags (MO, LA) and billing/benefit PA (B/D PA) indicate additional utilization management controls — providers should consult the formulary legend and submit PA or exception requests as applicable. |
Quantity Limits (Examples and Per-Drug Values)
Site-of-Care Notes and Infusion Requirements
Definitions and Abbreviations
Background and Document Purpose
This document is the CareSource MyCare Ohio formulary (the List of Covered Drugs) that sets out which drugs the plan covers and identifies utilization management controls (such as PA, QL, ST, and other requirement codes). It explains coverage conditions, how temporary supplies and transitions are handled, and provides contact information for members and providers to request exceptions or clarification.
Biosimilar and Biological Product Substitution
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