CareSource Dual Advantage Formulary (Drug List) — Coverage Criteria
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Describes the prescription drugs covered by the CareSource Dual Advantage (HMO D-SNP) plan, how to use the formulary, and coverage controls (prior authorization, quantity limits, step therapy) for members and prescribing providers.
No material clinical or coverage changes in this revision.
Coverage rules and formulary controls
Formulary Coverage and Controls
Covered when plan rules and site/network requirements are met.
See Evidence of Coverage for details.
See formulary Requirements /Limits codes for per‑drug controls (PA, QL, ST, MO, LA, NDS, B/D PA).
Formulary Exception Criteria
Formulary exceptions and coverage waivers are considered under the following logic.
Prescriber must submit supporting medical rationale; standard decision timeframe is 72 hours and expedited (urgent) requests with a prescriber statement are decided within 24 hours.
If approved, coverage and cost‑sharing are applied per the decision (e.g., non‑formulary approvals remain at pre‑determined cost‑sharing).
Temporary Supply / Transitional Coverage
Temporary supply coverage rules.
If coverage is not approved after the initial 30‑day supply, the plan will not pay for subsequent fills.
Applies to LTC residents past the first 90 days of membership or to specified transitions of care (hospital discharge, hospice change, facility discharge, etc.).
Applies to the specified transition events listed in policy.
General coverage rules for listed agents
Coverage is determined per listed drug/formulation when ALL of the following apply:
Listing indicates coverage is subject to the Requirements /Limits field for that line item.
Requirements /Limits codes (PA, MO, QL, NDS, LA, B/D PA, ST) on each drug line must be satisfied for coverage.
Some agents (IV/infusible/specialty) may require administration in specified settings and follow site‑of‑care rules.
Non‑maintenance formulary changes generally will not discontinue or reduce coverage of drugs during the 2026 coverage year for members already taking them. Members who are currently using a drug that remains on their plan will continue to receive it at the same cost‑sharing and with no new restrictions for the remainder of the 2026 coverage year; changes that do not affect the member will not generate a direct notice. Note that formulary changes may take effect for all members on the next benefit year (for example, January 1 of the following year).
Source material: CareSource statement on formulary changes and the 2026 coverage year.
If a drug is not included on the formulary and an exception is not granted, the member may be responsible for the full cost of the medication. Members should contact Member Services to confirm coverage and request a list of covered alternatives to discuss with their prescriber, or submit a formulary exception request with supporting medical rationale so the plan can consider covering the non‑formulary drug.
There are no explicit plan exclusions stated within this segment of the formulary extract. The fragment lists covered agents and applicable Requirements/Limits flags but does not present any standalone exclusion statements in these chunks.
This excerpt does not contain specific exclusion language; instead, the drug table uses abbreviated Requirement/Limits codes (for example, PA, MO, QL, NDS, LA, B/D) whose full definitions and any exclusionary rules are provided at the start of the complete formulary table. Refer to the table header/legend in the full formulary for the authoritative meanings of those abbreviations.
No entries in this segment explicitly list conditions or situations described as 'not medically necessary.' The fragment shows drugs with usage flags (PA, MO, QL, NDS) but does not enumerate 'not medically necessary' determinations in these chunks.
Formulary coding, NDCs, and dosage annotations
| No codes listed |
| 300 mg/15 ml | irinotecan intravenous solution (concentration/supply) |
| 500 mg/25 ml | irinotecan intravenous solution (concentration/supply) |
| 40 mg/2 ml | irinotecan intravenous solution (concentration/supply) |
| 3 mg | ITOVEBI ORAL TABLET 3 MG |
| 9 mg | ITOVEBI ORAL TABLET 9 MG |
| 100 mg | imatinib oral tablet 100 mg |
| 400 mg | imatinib oral tablet 400 mg |
| 10 mg/day | LENVIMA ORAL CAPSULE dosing pattern listed |
| 12 mg/day | LENVIMA dosing pattern |
| 14 mg/day | capsule dosing patterns (multiple drugs) |
| 100 mcg/ml; 500 mcg/ml; 1000 mcg/ml | octreotide acetate injection solution concentrations |
| NDCS starting with 61314 | PYZCHIVA (only NDCs starting with 61314) intravenous and subcutaneous presentations |
Prior authorization, step therapy, documentation, and denial risks
Prior authorization required
Prior Authorization Required: CareSource requires prior authorization (PA) for many drugs and drug formulations listed in the formulary. Providers or prescribers must obtain approval from CareSource before dispensing PA‑flagged products; claims for items requiring PA may be denied if authorization is not obtained.
- PA = Prior Authorization — approval required before fill; absence of PA may result in non‑coverage or claim denial.
- PA appears widely in the Requirements/Limits column across formulary (including oncology, specialty, biologic, infusion, IV, and oral agents).
PAXLOVID prior auth / quantity limits
PAXLOVID: Specific prior authorization and quantity limits apply. Some PAXLOVID dose packs are listed with site/medical override (MO), NDS flags, and explicit QL entries (for example QL 28/28 days or QL 30/30 days depending on pack). Providers must follow the listed Requirements/Limits for the exact package/NDC.
- PAXLOVID dose packs: some entries show MO; NDS; others show PA; MO; QL (28 per 28 days) or QL (30 per 30 days).
- Dispense only per the QL shown for the specific pack size to avoid denial.
Prior authorization required for select agents
Prior authorization is required for select agents (including many specialty, infusion, oncology, and biologic products). Prescribers must request PA before dispensing these agents to ensure coverage.
- Examples of select agents with PA flags: intravenous antibiotics, antiviral IV/PO formulations, selected oncology and specialty agents.
- Some entries additionally show B/D PA (benefit/design PA) or site flags — follow the exact Requirements/Limits for each product.
Prior authorization required for many drugs
Prior authorization is required for many drugs across the formulary; PA is used alongside other controls (MO, QL, LA, ST, NDS, B/D PA) to manage utilization. Verify Requirements/Limits for each product before dispensing.
- PA often appears with MO (medical override), QL (quantity limits), LA (limit by administration site), ST (step therapy), and NDS (non‑drug specific notes).
- B/D PA denotes benefit/design prior authorization pathways for certain products (e.g., some oncology agents, biologics).
Prior authorization requirements
Prior authorization requirements: when PA is indicated in the Requirements/Limits column, prescribers must submit the supporting clinical documentation requested by CareSource. Follow the table legend for symbol definitions and exact procedural expectations.
- Refer to the table header/legend for abbreviation meanings (PA, QL, ST, MO, NDS, LA, B/D PA).
- PA requests typically require a prescriber statement and clinical rationale; see formulary/web resources for PA forms and instructions.
Prior authorization required for listed specialty/biologic products
Numerous listed drugs (including specialty/biologic products such as REPATHA, OTULFI, TREMFYA, PYZCHIVA, TREMFYA, and other high‑cost injectables) are flagged with PA and often QL and MO. These products commonly require prescriber‑submitted documentation prior to coverage.
- Specialty biologics frequently show PA; many also include QL values (e.g., 0.5 per 28 days, 1 per 28 days, or per‑period limits).
- B/D PA entries appear for certain biologics and oncology drugs — confirm the correct PA pathway.
Authorization indicators present
Authorization indicators present: the formulary uses abbreviations (PA, MO, QL, ST, LA, NDS, B/D PA) to signal utilization management and approval pathways. Providers must interpret these abbreviations per the table legend and comply before dispensing.
- PA = Prior Authorization; QL = Quantity Limit; ST = Step Therapy; MO = Medical Override; LA = Limit by Administration site; NDS = Non‑Drug Specific notes; B/D PA = Benefit/Design PA.
Prior authorization risk / Denial triggers
Denial risk: failure to obtain prior authorization, exceed a quantity limit, or neglect required medical override/step therapy rules may result in claim denial or non‑coverage. Providers should confirm approvals before dispensing to avoid patient or provider liability.
- Claims for PA‑flagged drugs may be denied if PA is not on file.
- Exceeding QL values or ignoring MO/ST requirements can also trigger denials.
Utilization management triggers and step therapy notes
Utilization management triggers used in the formulary include PA, MO, QL, ST, LA, NDS, and B/D PA. These flags determine additional administrative steps required for coverage and may vary by product, formulation, or package size.
- Use the Requirements/Limits column for each NDC/package to identify the specific triggers and follow the appropriate authorization or documentation process.
- Step therapy (ST) is present for some products (e.g., select injectables and certain oral agents); where ST is shown, document failure or contraindication of the required step before requesting coverage for later‑line agents.
Quantity limit documentation
Quantity limits and quantity‑limit documentation: many formulary entries include explicit QL values (for example, 28 per 28 days, 30 per 30 days, 2 per 28 days). Dispensing beyond the stated QL without an approved exception or override risks denial.
- Follow the QL shown for the specific product packaging/NDC and the time window specified (per 28 days, per 30 days, per 180 days).
- If additional quantity is clinically necessary, request an exception/waiver with supporting prescriber documentation per the formulary exception process.
Documentation for restrictions and required prescriber support
Documentation for restrictions and required supporting materials: when PA, MO, ST, QL, LA, NDS, or B/D PA are indicated, providers must submit the prescriber’s clinical statement and any requested supporting records. Exception requests require a prescriber rationale and are generally decided within 72 hours (24 hours for expedited requests when clinically appropriate).
- When requesting an exception to prior authorization, quantity limits, or step therapy, the prescriber must explain the medical necessity.
- Expedited review (24 hours) is available when waiting would seriously harm the member; otherwise standard review is within 72 hours.
Reference for abbreviations
Reference for abbreviations / symbol definitions: see the table legend at the beginning of the formulary for full definitions of PA, QL, ST, MO, NDS, LA, B/D PA and other symbols used throughout the Requirements/Limits column.
- Always consult the table header/legend before interpreting a Requirements/Limits entry.
- The legend clarifies which flags require prior authorization versus other administrative actions.
Step therapy and related program controls
| Step therapy rule | Description |
|---|---|
| Must try specified preferred agent(s) before coverage of non-preferred agent is approved | |
| For some conditions the plan requires trying a specified formulary drug first; the plan will cover an alternative only after failure or intolerance of the required agent (see formulary and Evidence of Coverage). |
| Step therapy rule | Description |
|---|---|
| Try formulary-preferred agent first | |
| CareSource may require that a formulary-preferred drug (Drug A) be tried and fail or be intolerable before covering an alternative (Drug B). See formulary entries for specific ST flags. |
| Specialty program examples | Controls/flags shown |
|---|---|
| CAYSTON | |
| Listed with Requirements/Limits = PA; MO; LA; QL (84 per 56 days); NDS (managed via specialty/site controls). | |
| TEFLARO | |
| Listed with Requirements/Limits = PA; MO; NDS (subject to program controls). | |
| SIRTURO | |
| Included among specialty/anti-infective listings with PA/MO and other program flags (see table). |
| Observation | Source note |
|---|---|
| B/D PA and step-like controls present | |
| Multiple specialty/oral oncology entries include B/D PA and other flags; explicit step sequences are not provided in this fragment. |
| Flag | Interpretation |
|---|---|
| MO | |
| Shown across entries; may indicate medical override/site or step management per table header definitions. | |
| LA | |
| Limited availability/site-of-care flag appears; may be used as part of step/management controls. | |
| B/D | |
| B/D PA appears (brand/dispense prior auth) indicating additional prior step or billing pathway. |
| Flag | Implication |
|---|---|
| B/D PA | |
| Indicates a brand/dispense prior authorization pathway; may require prior steps or criteria before coverage. | |
| PA | |
| Prior authorization flag present across many entries; may signal required prior steps or clinical criteria. |
| Summary | Source |
|---|---|
| Step therapy not explicitly detailed in this excerpt | |
| Fragment frequently shows MO and PA flags but does not include full step-sequence details or failure criteria. |
| Starter/titration reference | Example from formulary |
|---|---|
| Starter and titration packs referenced | |
| Entries include 'STARTING PACK', 'INITIATION PK', and dose packs (e.g., VENCLEXTA STARTING PACK; EXXUA 24HR DOSE PACK) implying staged initiation. |
| Product | Step therapy (ST) note |
|---|---|
| ARISTADA formulations | |
| Some ARISTADA intramuscular suspension entries are listed with Requirements/Limits including ST (step therapy) and QL values. |
| Rule | Formulary indication |
|---|---|
| ST applies where listed in Requirements /Limits | |
| Formulary lines show 'ST' on specific rows (providers must follow the Requirements/Limits field where ST is indicated). |
| Products with ST noted | Formulary reference |
|---|---|
| RALDESY | |
| Listed with Requirements/Limits = ST; MO; NDS (ST indicated for this product). | |
| Methylphenidate formulations | |
| Certain methylphenidate entries include ST in Requirements/Limits (see formulary lines showing ST; MO; QL). |
| Observation | Implication |
|---|---|
| B/D PA and PA / MO flags indicate benefit-design or step controls | |
| Some products are flagged B/D PA and MO indicating benefit/benefit-design or step-level controls; explicit multi-step sequences are not present in this excerpt. |
Quantity limits by drug and formulation
Site-of-care and administration restrictions
Abbreviations and glossary
Context and biosimilar policy notes
Background: biological products are inherently more complex than typical small‑molecule drugs and the formulary recognizes biosimilar alternatives. The plan may manage biologicals and their biosimilars through tiering, substitution, or application of utilization controls; interchangeability and substitution rules depend on the product and applicable state law. For specifics on how the plan treats biosimilars and substitution of original biologics, see the formulary’s biosimilar guidance and the Evidence of Coverage.
Policy revision and effective dates
Formulary effective date: 04/01/2026; this document shows the formulary identifier as Formulary ID: 00026138 and indicates the drug list was last updated on 03/13/2026. The policy header also records a last review on 04/01/2026.
Additional timing: standard decision timelines for formulary exceptions are noted as 72 hours (standard) and 24 hours (expedited with prescriber statement); temporary supply rules allow a 30‑day transitional supply (and in certain long‑term care or limited access situations a 31‑day emergency supply).
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