CareSource Dual Advantage Formulary Coverage & PA

Formulary Coverage and Controls

Covered when plan rules and site/network requirements are met.

General formulary coverage: Drug is generally covered if it is listed on the formulary, is medically necessary, dispensed at a CareSource Dual Advantage network pharmacy, and other plan rules are followed.

See Evidence of Coverage for details.

Coverage controls: Coverage may be subject to utilization management controls such as prior authorization, quantity limits, and step therapy as indicated for specific drugs.

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.

Formulary exception approval conditions: An exception to the formulary or a waiver of a restriction (PA, ST, or QL) will generally be approved when the prescriber documents that formulary alternatives would not be as effective for the member or would cause adverse effects, or that applying the restriction would not be as effective for the member.

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.

Exception procedures: Member or prescriber must request an exception and provide the required clinical justification; CareSource will make a decision within the stated timelines.72 hours (standard); 24 hours (expedited)

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.

Initial temporary supply: Plan will cover a temporary 30‑day supply for each non‑formulary or restricted drug during initial coverage while the member pursues an exception or waiver.30 days

If coverage is not approved after the initial 30‑day supply, the plan will not pay for subsequent fills.

Emergency or transitional supply: For long‑term care residents or certain transitions in care, the plan may provide a one‑time emergency/temporary supply up to 31 days while the member pursues a formulary exception.31 days

Applies to LTC residents past the first 90 days of membership or to specified transitions of care (hospital discharge, hospice change, facility discharge, etc.).

One‑time site‑of‑care transition supply: If the treatment setting changes (e.g., hospital discharge to home, transition from Part A facility coverage to Part D), the plan may cover a one‑time temporary supply up to 31 days.

General coverage rules for listed agents

Coverage is determined per listed drug/formulation when ALL of the following apply:

Formulary presence: The specific drug and formulation is listed in the in‑network prescription drug benefits table for the plan.

Listing indicates coverage is subject to the Requirements /Limits field for that line item.

Utilization controls complied: The provider and member comply with any utilization management controls shown on the drug line (for example, obtain Prior Authorization (PA), meet Step Therapy (ST) requirements, or adhere to Quantity Limits (QL)).

Requirements /Limits codes (PA, MO, QL, NDS, LA, B/D PA, ST) on each drug line must be satisfied for coverage.

Network and site requirements met: Dispensing occurs through an in‑network pharmacy or the appropriate site of care as required (LA, B/D PA may indicate site or Part B/Part D billing distinctions).

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 explicit billing codes in this segmentmixed

No codes listed

Formulations and strengths notedmixed

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

Dosage/supply annotationsmixed

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

NDC group notedNDC

NDCS starting with 61314

PYZCHIVA (only NDCs starting with 61314) intravenous and subcutaneous presentations

Example quantity limit — atorvastatin 40 mg

Drugatorvastatin 40 mg

Quantity limit1 tablet per day per prescription

Source noteListed as example QL in formulary restrictions section

Quantity limits examples — posaconazole

Drugposaconazole oral tablet, delayed

Quantity limitQL (96 per 30 days) depending on entry

Alternate designationMay be listed NDS (limited to 30-day supply) for some rows

Quantity limits examples — multiple entries

Example 1MAVYRET ORAL TABLET — QL (84 per 28 days)

Example 2PAXLOVID ORAL TABLETS, DOSE PACK 300 MG — QL (30 per 30 days) or QL (28 per 28 days) depending on row

Example 3cefuroxime sodium IV recon soln 7.5 g — QL (20 per 10 days)

Quantity limits examples — selected QL patterns

Example QL setExamples include QL (20 per 10 days); QL (224 per 28 days); QL (4 per 10 days); QL (80 per 10 days)

ContextThese appear on IV/anti‑infective lines and other formulary rows with NDS/PA flags

ImplicationDispensing must not exceed stated time‑period limits unless override documented

Quantity limits examples — common QL patterns

Representative QLsExamples include QL (324 per 30 days); QL (90 per 30 days); QL (28 per 28 days); QL (120 per 30 days)

Where shownAppears across oncology and specialty oral/IV product listings

LegendQL values shown alongside PA/MO/NDS in Requirements/Limits column

Prior authorization, step therapy, documentation, and denial risks

Prior Authorization

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).

Prior Authorization

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

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

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).

Documentation Required

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

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.

Note

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.

Denial Risk

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.

Step Therapy

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.

Documentation Required

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 Required

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.

Note

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

atorvastatin 40 mg — unit

Drugatorvastatin 40 mg

Packaged unit1 tablet

ApplicationExample tablet/day QL used in formulary explanations

posaconazole entries — QL/NDS

Drugposaconazole oral tablet, delayed

Quantity limitQL (96 per 30 days)

Alternate listingMay be shown as NDS (limited to 30-day supply) in some rows

Maintenance medications supply limits

Maintenance supply limitsSome meds limited to 30-day retail/mail supply; extended supplies limited to 90- or 102-day depending on channel

Legend referenceNDS indicates 30-day limit (see table header)

Practical noteUse mail-order for long-term maintenance to access extended day supplies

itraconazole oral capsule — QL 120

Drugitraconazole oral capsule

Quantity limit120 per 30 days

RequirementsListed with MO and QL in formulary

ganciclovir sodium IV recon soln — QL 168

Drugganciclovir sodium IV recon soln

Quantity limit168 per 28 days

Related entriesAppears with B/D PA and MO flags in antiviral section

MAVYRET ORAL TABLET — QL 84

DrugMAVYRET ORAL TABLET

Quantity limit84 per 28 days

RequirementsPA; MO; QL; NDS noted

PAXLOVID ORAL TABLETS, DOSE PACK 300 MG — QL 30

DrugPAXLOVID ORAL TABLETS, DOSE PACK 300 MG

Quantity limit30 per 30 days (and some rows show 28 per 28 days)

RequirementsPA; MO; QL flags across entries

PREVYMIS ORAL TABLET 240 MG — QL 56

DrugPREVYMIS ORAL TABLET 240 MG

Quantity limit56 per 28 days

Alternate strength480 mg listing shows QL (28 per 28 days)

cefuroxime sodium IV recon soln 7.5 g — QL 20

Drugcefuroxime sodium IV recon soln 7.5 g

Quantity limit20 per 10 days

NotesListed with NDS and appears in antiinfective section

cefuroxime sodium IV recon soln 7.5 g — QL 20 (duplicate)

Drugcefuroxime sodium IV recon soln 7.5 g

Quantity limit20 per 10 days (duplicate entry)

SourceSame QL appears across multiple rows in the antiinfective table

meropenem IV recon soln 500 mg — QL 10

Drugmeropenem IV recon soln 500 mg

Quantity limit10 per 10 days

RequirementsPA; QL indicated in formulary

vancomycin IV recon soln 5 g — QL 4

Drugvancomycin IV recon soln 5 g

Quantity limit4 per 10 days

NotesListed with QL and MO in IV antibiotic rows

vancomycin oral capsule 125 mg — QL 40

Drugvancomycin oral capsule 125 mg

Quantity limit40 per 10 days

RequirementsPA; MO; QL flags shown

abiraterone oral tablet 250 mg — QL 120 or 60

Drugabiraterone oral tablet 250 mg

Quantity limitQL (120 per 30 days) or QL (60 per 30 days) depending on listing

ContextMultiple entries show differing QLs by strength/formulation

BOSULIF formulations — QL examples

DrugBOSULIF formulations

Quantity limit examplesQL examples shown: 30 per 30 days; 56 per 28 days; 112 per 28 days (varies by form)

RequirementsPA; MO; QL flags noted across entries

BRUKINSA — QL 84

DrugBRUKINSA oral tablet

Quantity limit84 per 28 days

RequirementsPA; LA; QL indicated

CALQUENCE — QL 60

DrugCALQUENCE (acalabrutinib)

Quantity limit60 per 30 days

RequirementsPA; LA; QL indicated in formulary

dasatinib 20 mg — QL 90

Drugdasatinib 20 mg

Quantity limit90 per 30 days

RequirementsPA; MO; QL noted

erlotinib — QL 120

Drugerlotinib (various entries)

Quantity limit120 per 30 days

RequirementsPA; MO; QL flags across rows

fulvestrant — QL 126

Drugfulvestrant

Quantity limit126 per 28 days

RequirementsPA; QL indicated

IBRANCE — QL 120

DrugIBRANCE (palbociclib)

Quantity limit120 per 30 days (other entries show 324 per 30 days for some formulations)

RequirementsPA; QL; NDS flags present

General large QL examples across drugs

Representative exampleSome entries across the formulary show large QLs (e.g., 324 per 30 days) depending on drug and formulation

ImplicationQLs vary widely by drug class and are displayed in Requirements/Limits

ReferenceSee oncology/specialty sections for per‑entry QLs

IBTROZI / IDHIFA — QL 90

DrugsIBTROZI; IDHIFA (examples)

Quantity limit90 per 30 days (example entries)

RequirementsPA and QL flags shown

KADCYLA / mitoxantrone — QL 28

DrugsKADCYLA; mitoxantrone examples

Quantity limit28 per 28 days

ContextTypically shown for IV oncology reconstructions

irinotecan — QL 21; 42

Drugirinotecan (various IV solutions)

Quantity limitsExamples include QL (21 per 28 days) and QL (42 per 28 days)

NotesValues vary by vial size/strength and row

NULOJIX — QL 24

DrugNULOJIX

Quantity limit24 per 28 days

RequirementsB/D PA; MO; NDS noted

OGSIVEO — QL 56

DrugOGSIVEO

Quantity limit56 per 28 days

RequirementsPA; QL specified

OJEMDA — QL 96

DrugOJEMDA (various forms)

Quantity limit96 per 28 days (suspension listing) and other per‑entry QLs

RequirementsPA; QL; NDS or B/D PA depending on row

pemetrexed — QL 90

Drugpemetrexed

Quantity limit90 per 30 days

RequirementsPA; MO; LA; QL indicated

PERJETA — QL 60

DrugPERJETA

Quantity limit60 per 30 days

RequirementsPA; QL indicated

ROMVIMZA — QL 300

DrugROMVIMZA

Quantity limit300 per 30 days

NotesLarge QL shown for oral solution/pack variants

Multiple QL examples vary by drug

SummaryMultiple QL examples vary by drug: 30/30; 60/30; 84/28; 90/30; 120/30; 224/28; 360/30 etc.

Where seenAcross oncology, neurology, and specialty formulary sections

ActionConfirm per‑line QL and Requirements/Limits before dispensing

VALTOCO — QL 10

DrugVALTOCO (select strengths)

Quantity limitQL (10 per 30 days)

RequirementsPA; MO; QL flags present

SYMPAZAN — QL 60 (alt 30)

DrugSYMPAZAN oral film

Quantity limitQL (60 per 30 days); alternate listing QL (30 per 30 days)

RequirementsPA; MO; QL indicated in formulary

topiramate — QL 28 per 180 days

Drugtopiramate formulations

Quantity limitQL (28 per 180 days)

NotesApplies to various topiramate forms (capsule/solution/tablet) in this fragment

BRIUMVI — QL examples

DrugBRIUMVI

Quantity limitQL (24 per 180 days); alternate listing QL (12 per 28 days)

RequirementsPA; MO; QL indicated

dimethyl fumarate — QL examples

Productdimethyl fumarate packs (120/240 mg)

Quantity limitsQL (56 per 28 days); other listings QL (120 per 180 days)

RequirementsPA; MO; QL flags

acetaminophen‑codeine solution — QL examples

Drugacetaminophen‑codeine oral solution

Quantity limitsExamples include QL (4500 per 30 days), QL (5550 per 30 days), QL (360 per 30 days)

RequirementsMO; QL flags vary by concentration/packaging

VUMERITY — QL 120

DrugVUMERITY

Quantity limit120 per 30 days

RequirementsPA; MO; QL indicated

ZEPOSIA — QL 30

DrugZEPOSIA

Quantity limit30 per 30 days

RequirementsPA; MO; QL indicated

buprenorphine transdermal patch — QL 4

Drugbuprenorphine transdermal patch

Quantity limit4 per 28 days

RequirementsPA; MO; QL indicated

fentanyl transdermal patch 72 hr — QL 10

Drugfentanyl transdermal patch 72 hr

Quantity limit10 per 30 days

RequirementsPA; MO; QL indicated in multiple rows

methadone intensol — QL 90

Drugmethadone intensol

Quantity limit90 per 30 days

RequirementsPA; MO; QL indicated

ABILIFY ASIMTUFII suspension 960 — QL 3.2

DrugABILIFY ASIMTUFII suspension 960

Quantity limit3.2 per 56 days (example) or 2.4 per 28 days in other rows

RequirementsMO; QL indicated

ARISTADA IM suspension — example QLs

ProductARISTADA IM suspension examples

Quantity limitsExamples include QL (30 per 365 days) or per‑entry QLs (e.g., 3.9 per 56 days; 1.6 per 28 days)

RequirementsMO; ST; QL flags vary by syringe strength

INVEGA syringe examples — QL variants

ProductsINVEGA HAFYERA / TRINZA / SUSTENNA syringes

Quantity examplesExamples include 0.88 per 90 days; 3.5 per 180 days; 0.75 per 28 days; 0.5 per 28 days depending on strength

RequirementsMO; QL; NDS flags indicated

Oral psychotropic agents — common QLs

CategoryOral psychotropic agents (examples)

Common QLsMany entries include QL (30 per 30 days; 60 per 30 days; 120 per 30 days)

RequirementsMO; QL flags vary by formulation/strength

INVEGA SUSTENNA 78 mg — QL 0.5 per 28 days

ProductINVEGA SUSTENNA 78 mg syringe

Quantity limit0.5 per 28 days

RequirementsMO; QL indicated

quetiapine — QL 90/60

Drugquetiapine oral tablet

Quantity limitsQL 90 per 30 days or QL 60 per 30 days depending on strength/formulation

RequirementsMO; QL indicated

risperidone microspheres 12.5 mg/2 ml — QL 2

Drugrisperidone microspheres IM suspension 12.5 mg/2 ml

Quantity limit2 per 28 days

RequirementsMO; QL indicated

risperidone microspheres 25 mg/2 ml — QL 2

Drugrisperidone microspheres IM suspension 25 mg/2 ml

Quantity limit2 per 28 days

Additional notesAlso includes PA/MO/NDS annotations in some rows

ZURZUVAE — QL 28 per 365 days

DrugZURZUVAE oral capsule 20/25 mg

Quantity limit28 per 365 days

RequirementsPA; MO; QL flags present

SODIUM OXYBATE — QL 540

DrugSODIUM OXYBATE (preferred NDCs)

Quantity limit540 per 30 days for certain entries

RequirementsPA; LA; QL flagged in some rows

enoxaparin 30/60 mg syringes — QL 16.8

Productenoxaparin subcutaneous syringe 30 mg/0.3 ml, 60 mg/0.6 ml

Quantity limitQL (16.8 per 28 days)

RequirementsMO; QL indicated in formulary

enoxaparin 120/80 mg syringes — QL 22.4

Productenoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml

Quantity limitQL (22.4 per 28 days)

RequirementsMO; QL indicated

ELIQUIS oral tablet — QL 60

DrugELIQUIS oral tablet

Quantity limitQL (60 per 30 days)

RequirementsMO; QL indicated

ELIQUIS suspension 0.5 mg — QL 140

DrugELIQUIS oral tablet for suspension 0.5 mg

Quantity limitQL (140 per 28 days)

RequirementsMO; QL indicated

HEPARIN 5,000 UNIT/ML — QL 775

ProductHEPARIN injection syringe 5,000 UNIT/ML

Quantity limitQL (775 per 28 days)

RequirementsMO; QL indicated

UPTRAVI — QL 60

DrugUPTRAVI oral tablet

Quantity limitQL (60 per 30 days)

RequirementsPA; MO; LA; QL indicated

REPATHA — QL 6

DrugREPATHA

Quantity limit6 per 28 days

RequirementsPA; QL indicated

OTULFI (IV) — QL 104

ProductOTULFI (IV)

Quantity limit104 per 180 days

RequirementsPA; MO; QL indicated

OTULFI (SC) — QL 0.5

ProductOTULFI (SC)

Quantity limit0.5 per 28 days

RequirementsPA; MO; QL indicated

PYZCHIVA (IV) — QL 104

ProductPYZCHIVA (IV)

Quantity limit104 per 180 days

NotesNDCs starting with 61314 referenced

TREMFYA PEN induction — QL 12

ProductTREMFYA PEN induction

Quantity limit12 per 180 days (induction pack)

RequirementsPA; MO; QL indicated

TREMFYA PEN — QL 6

ProductTREMFYA PEN maintenance

Quantity limit6 per 28 days

RequirementsPA; MO; QL indicated

Abbreviations and glossary

Abbreviation definitions used in formulary

PAPrior Authorization — approval required before the drug will be covered

MOMedical Override / Mail-Order designation — review or channel restriction may apply

QLQuantity Limit — maximum quantity allowed within a specified time period (e.g., '60 per 30 days')

NDSNDS — indicates limitation to 30-day supply at retail or mail-order (table header definition)

PA — Prior Authorization definition

PAPrior Authorization — Plan requires approval from CareSource before coverage; failure to obtain may result in noncoverage

ContextShown in Requirements/Limits column for many drugs

Action for providersSubmit prior authorization request with supporting medical documentation per formulary processes

MO — Medical Override / Mail-Order definition

MOMO — Mail-Order / Medical Override designation; may indicate channel-specific dispensing or special review

ImplicationMO entries often reference suitability for mail-order or require medical review

Provider actionFollow channel instructions (retail vs mail) and supply documentation if MO override requested

QL — Quantity Limit definition

QLQuantity Limit — maximum amount covered within specific time period (e.g., '60 per 30 days')

ExamplesMany formulary lines show QL values (e.g., 30/30, 60/30, 120/30, 28/28)

ImplicationDispensing beyond QL may require prior authorization or documentation

NDS — Non-Drug-Specific designation

NDSNDS — indicates drug is limited to a 30-day supply at retail or mail-order per table header

UsageOften appears alongside QL/PA to denote supply restriction

ReferenceSee table header 'List of Abbreviations' for full legend

PA (table header) — legend reference

Table header termPA (Prior Authorization) — legend referenced at table start

PurposeIndicates requirement to obtain plan approval before coverage

Provider notePA shown per‑line in Requirements/Limits; follow PA submission process

MO (table header) — legend reference

MO (table header)MO — Mail-Order / Medical Override as defined in list of abbreviations

MeaningMay indicate channel or special review requirements

Provider actionCheck row-specific notes for MO requirements

QL (table header) — legend reference

QL (table header)Quantity Limit — specified as amount per time period (e.g., '96 per 30 days')

Examples in documentMultiple entries across the formulary show QL values

ImplicationAdhere to per‑line QL or obtain documentation for override

PA — Requirements/Limits meaning

PA requirementPrior authorization indicated in Requirements/Limits — approval required before coverage

ConsequenceWithout PA, the plan may not cover the drug

Where shownPA appears across many drug rows in the formulary table

QL — Requirements/Limits meaning

QL meaningQuantity Limit listed in Requirements/Limits — maximum covered quantity/timeframe

ExamplesShown as 'QL (96 per 30 days)', 'QL (60 per 30 days)', etc.

ActionClaims exceeding QL may require supporting documentation or PA

MO — Requirements/Limits meaning

MO meaningMO may indicate medical override or mail-order designation and appear in Requirements/Limits

Operational noteFull definition available at table header; follow per-entry instructions

Provider actionProvide clinical justification if requesting MO override

Abbreviations in Requirements /Limits (legend)

Legend summaryAbbreviations used in Requirements/Limits include PA, MO, QL, LA, NDS (see beginning of table for full definitions)

ImplicationThese flags indicate utilization controls that must be followed for coverage

ReferenceConsult formulary table header for exact operational definitions

OpenPayer

CareSource Dual Advantage Formulary (Drug List) — Coverage Criteria

Coverage rules and formulary controls

Formulary coding, NDCs, and dosage annotations

Prior authorization, step therapy, documentation, and denial risks

Step therapy and related program controls

Quantity limits by drug and formulation

Site-of-care and administration restrictions

Abbreviations and glossary

Context and biosimilar policy notes

Policy revision and effective dates