CareSource Dual Advantage Plus Formulary (Drug List)
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This document is the plan formulary (Drug List) for CareSource Dual Advantage Plus (HMO D-SNP) current as of 04/01/2026 and details covered drugs, tiers, and restrictions (prior authorization, quantity limits, step therapy, mail-order, limited availability, non-extended day supply) for in-network pharmacies.
Formulary updated on 04/01/2026 and posted monthly; members notified of mid-year changes per Medicare rules.
Multiple drug-tier and Requirements/Limits entries updated as of 03/13/2026.
Drug list last updated on 03/13/2026 (noted multiple times).
This part of the drug list indicates 'This drug list was last updated on 03/13/2026' multiple times.
This part indicates the drug list was last updated on 03/13/2026.
This drug list was last updated on 03/13/2026 and the overall formulary was updated on 04/01/2026.
Coverage Summary
Formulary Coverage Conditions and Exceptions
Covered when ALL of the following are met:
ALL of the following
- Prescription is filled at a CareSource Dual Advantage Plus network pharmacy.
- Drug is determined to be medically necessary for the member's condition by the prescriber.
- Member and prescriber have met any applicable Formulary Requirements and Limits for the listed drug (see requirements and limits below).
See 'Formulary Requirements and Limits (listing-level)' for specific codes and flags applied to individual formulary entries.
- Coverage follows any active prior authorization, step therapy, and quantity limit rules applied to the drug.
Exception (Formulary/Tiering/Restriction) Requests
Exception requests are considered when the following conditions are met:
ALL of the following
- An exception request is submitted by the member or prescriber with supporting clinical information demonstrating medical necessity or why standard formulary requirements should be waived.
- CareSource will decide standard (non-urgent) exception requests within 72 hours of receipt, and expedited (urgent) requests within 24 hours when the member's health could be seriously harmed by waiting for a standard decision.
Expedited determinations apply when prescriber indicates that waiting 72 hours could seriously jeopardize the member's health or ability to regain maximum function.
- If an exception is granted, coverage will be provided according to the approval terms (duration, quantity, renewal requirements).
- Members may be eligible for interim coverage (see Temporary Coverage During Transitions) while exception requests are pending in certain circumstances.
Temporary Coverage During Transitions
Temporary coverage may be provided during transitions of care and when members are new to the plan under these conditions:
ALL of the following
- New members transitioning to CareSource who have an active prescription for a non-formulary or restricted drug may receive a one-time temporary supply to allow time for the member and prescriber to pursue a formulary alternative or exception request.
Temporary supply periods and quantities depend on the situation described below.
Temporary supply rules
- Standard transition supply: up to a 30-day supply of the current medication (or the equivalent), provided at a network pharmacy while the formulary exception or prior authorization is processed.
- If the member’s prior plan allowed a 31-day supply and state law or contractual terms require it, a 31-day temporary supply may be permitted.
- Temporary coverage does not waive applicability of subsequent prior authorization, step therapy, or quantity limits after the temporary supply period ends; prescriber must complete any required requests to continue therapy.
- Transition supplies are intended to avoid gaps in therapy and are provided only once per drug per transition event unless otherwise permitted by plan policy or regulation.
Requirements & Limits (PA, QL, ST, NDS, LA)
Requirements / Limits taxonomy
Each drug entry includes one or more requirement/limit flags. Interpretation: coverage requires adherence to listed requirements/limits.
PA defined in table legend
MO defined in table legend
LA defined in table legend
B/D PA explained in abbreviation list
QL numeric examples provided throughout the drug list
NDS defined in table legend
Formulary coverage requirements by drug/formulation
Each listed drug/formulation is associated with specific requirement flags; coverage is conditional per those flags.
Example entry appears in drug table
Listed with B/D PA or PA depending on line
Shows how per‑product flags map to coverage conditions
Limited availability (LA) shown for some products
Multiple entries illustrate mapping of flags to coverage
Actions Required by Providers
Prior Authorization required for listed drugs
Obtain prior authorization (PA) before dispensing any drug annotated with the PA requirement; failure to obtain PA may result in denial of coverage.
- PA must be obtained prior to dispensing for drugs marked 'PA'.
- Examples in formulary entries show many PA-flagged drugs (e.g., VOSEVI, CAYSTON, ADCETRIS).
Exception requests require prescriber medical justification
Exception (coverage/tiering restriction) requests must include a prescriber’s medical justification explaining why formulary alternatives or the restriction would be ineffective or harmful. Standard decisions are made within 72 hours of receiving the prescriber’s supporting statement; expedited (fast) decisions are available and must be decided within 24 hours if the prescriber indicates and the plan agrees the member could be seriously harmed by waiting.
- Prescriber must explain medical reasons why alternatives/restrictions are inappropriate.
- Standard decision time: 72 hours; expedited decision time: 24 hours.
Network pharmacy requirement
Prescriptions must be filled at a CareSource Dual Advantage Plus network (in‑network) pharmacy for Part D coverage. If filled out-of-network, the member may be responsible for the full cost.
- Network pharmacy required for prescription drug benefit.
- Out-of-network fills may result in full member liability.
Step therapy enforcement
Follow step‑therapy (ST) requirements for drugs annotated 'ST' — the plan requires trial of specified first‑line agents before covering subsequent agents; document prior trials and clinical rationale when requesting overrides or exceptions.
- ST requires trial of specified drugs before later agents are covered.
- Document prior therapy and clinical rationale when requesting an exception or override.
Specialty routing, NDC and NDS handling
For NDS/LA/B/D PA and NDC‑restricted products, route specialty or limited‑availability drugs per plan instructions and bill using allowed NDCs. Drugs with NDS/LA or NDC‑only flags often require specialty pharmacy handling or specific NDC billing to receive the indicated coverage or tiering.
- Some products list 'ONLY NDCS' or NDC ranges — bill with allowed NDCs to match coverage.
- LA/NDS flags indicate limited distribution or specialty routing; follow plan specialty pharmacy rules.
Applicable Codes & Formulary Abbreviations
| PA | Prior Authorization required |
| QL | Quantity Limit |
| ST | Step Therapy required |
| NDC | National Drug Code (product-specific) |
| GC | Generic Common |
| BR | Brand |
| OTC | Over-the-Counter |
| ABIRATERONE 250 MG | Oral tablet; Tier and prior auth may apply |
| ABIRATERONE 500 MG | Oral tablet; Tier and prior auth may apply |
| ALECENSA 150 MG | Oral capsule; specialty tier likely; PA may apply |
| ALUNBRIG ORAL TABLET 30 MG | High-cost oncology agent; PA required |
| ALUNBRIG ORAL TABLET 90 MG | High-cost oncology agent; PA required |
| ALUNBRIG ORAL TABLET 180 MG | High-cost oncology agent; PA required |
| ADSTILADRIN | Intravesical therapy; PA and site-of-care rules may apply |
| AKEEGA | Specialty oral; PA and QL may apply |
| ADCETRIS | Specialty injectable; PA required |
| VIREAD ORAL TABLET 150 MG | Antiviral; tiering applies |
| CRESEMBA ORAL | PA required for most indications |
| ABIRATERONE ORAL TABLET 250/500 MG | PA required |
| ALECENSA | PA required |
| ALUNBRIG (all strengths) | PA required |
| ADCETRIS | PA required |
| ADSTILADRIN | PA required |
| AKEEGA | PA required |
| BRADE/BLENREP/BRUKINSA (selected biologics) | Specialty biologics — PA required |
| DAPTOMYCIN INTRAVENOUS RECON SOLN 350 MG | PA required for inpatient outpatient claim review |
| DAPTOMYCIN INTRAVENOUS RECON SOLN 500 MG | PA required |
| XIFAXAN 550 MG | Quantity Limit typically 2 tablets/day for hepatic encephalopathy; QL applies |
| VIREAD (various strengths) | Standard dispensing QL based on indication |
| METHOTREXATE ORAL (oncology vs rheumatology) | Different QLs by indication; prior auth may also be required |
| Doxy-100 | Doxycycline 100 mg — standard QL applies |
| SULFAMETHOXAZOLE-TRIMETHOPRIM IV | QLs apply for inpatient/outpatient dosing |
| VANCOMYCIN ORAL CAPSULE 125 MG/250 MG | QLs may apply; separate IV formulations have separate QLs |
| NDC: amphotericin b liposome | Product-specific coverage; NDC-restricted; PA may apply |
| NDC: CRESEMBA ORAL | NDC-level restrictions for oral formulations |
| NDC: fluconazole in NaCl IV piggyback 200 mg/100 ml | NDC-specific IV piggyback product; coverage restricted to specified NDCs |
| NDC: valganciclovir oral recon soln | NDC-specific; liquid reconstructions may be limited |
| NDC: ceftazidime injection recon soln 1 gram | NDC-restricted; PA/step and site-of-care rules may apply |
| NDC: ceftazidime injection recon soln 2 gram | NDC-restricted |
| NDC: ceftazidime injection recon soln 6 gram | NDC-restricted |
| NDC: cefuroxime sodium injection recon soln 750 mg | NDC-specific IV product restrictions |
| NDC: cefuroxime sodium intravenous recon 7.5 gram | NDC-specific |
| NDC: cephalexin oral suspension for reconstitution | NDC-restricted pediatric formulations |
Background & Definitions
This Drug List (formulary) is the CareSource Dual Advantage Plus (HMO D‑SNP) Drug List (Formulary) current as of 04/01/2026. It was developed with clinician consultation and lists the Part D covered drugs for the plan, organized by drug/treatment categories and an alphabetical index. The formulary shows each drug's plan tier and any utilization management controls that apply, including Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), Mail‑Order (MO), Limited Access (LA), Non‑Extended Days' Supply (NDS), and B/D PA where a drug may be billed under Part B or Part D depending on setting.
The Drug List explains how to find drugs (by medical condition grouping or the index), definitions for generics and biosimilars, and the meaning of the requirement/limit abbreviations shown on each drug row. It describes member protections and procedures for mid‑year formulary changes: immediate substitutions (for certain new generics/biosimilars), removals, or other changes follow Medicare rules and are posted monthly, and affected members will be notified at least 30 days before a change takes effect or may receive a 30‑day supply when requesting a refill.
Members or prescribers may request exceptions (coverage, tiering, or to waive PA/QL/ST) by providing clinical justification. The plan generally decides standard exception requests within 72 hours of receiving the prescriber's supporting statement and provides expedited (24‑hour) review when waiting could seriously harm the member.
The formulary emphasizes that drugs are covered when medically necessary, filled at a CareSource Dual Advantage Plus network pharmacy, and when listed requirements/limits are met; out‑of‑network fills may result in full member liability. The document and online postings (updated monthly) show the list of covered Part D drugs, tiers, and the specific requirement/limit flags for each product entry.
| Term | Definition |
|---|---|
| PA | |
| Prior Authorization — plan requires approval before coverage | |
| QL | |
| Quantity Limit — plan limits the amount covered (numeric per time period) | |
| ST | |
| Step Therapy — required trial of specified drugs before others are covered | |
| MO | |
| Mail-Order Drug / Medical Override / Managed Option — available via mail order; may indicate medical necessity review (document uses MO) | |
| NDS | |
| Non-Extended Days' Supply — limited to 30-day supply at retail or mail-order | |
| LA | |
| Limited Availability — may be available only at certain pharmacies | |
| B/D PA | |
| May be covered under Part B or Part D depending on use/setting; information may be required | |
| V | |
| Vaccine — provided at no cost when used per ACIP (vaccine designation) |
Formulary Entries & Examples
This part highlights representative, high‑impact formulary patterns and sample entries drawn from the indexed drug entries: specialty/high‑tier biologics and oncology agents with frequent PA/LA/NDS flags, vaccines and preservative‑free (PF) vaccine rows, insulin products and related devices (pens, pen needles, Omnipod entries), and multiple products showing QL numeric thresholds. The index also contains examples of NDC‑specific restrictions (e.g., albuterol HFA limited to listed NDC prefixes).
The index and code groups include many individual drug/Tier/Requirements lines (examples shown in the formulary tables), but this section does not duplicate the full product list or page‑level coverage details. For full, page‑level coverage, exact QL values, NDC restrictions, and the complete Requirements/Limits columns, consult the full formulary pages and index referenced in the document.
| GARDASIL 9 (PF) | Tier 1; Requirements = V |
| HEPLISAV-B (PF) | Tier 1; Requirements = B/D PA; V |
| HIBERIX (PF) | Tier 3; Requirements = (V/none listed) |
| VARIVAX (PF) | Tier 1; Requirements = V |
| VAQTA R SUSPENSION 50 UNIT/ML | Example vaccine row with QL (1 per 720 days) |
| INSULIN products index | Includes many insulin brands/formulations (LANTUS, HUMALOG, NOVOLIN, NOVOLOG, TOUJEO, LYUMJEV, FIASP) with MO, PA and QL flags |
| PEN NEEDLE / OMNIPOD devices | Device index lists OMNIPOD (GEN4/GEN5), PEN NEEDLES, insulin syringes |
| GVOKE / GVOKE HYPOPEN | Emergency glucagon products listed; QL/ MO flags present |
| ENBREL SURECLICK | QL (8 per 28 days); PA; MO; NDS |
| XEMBIFY | B/D PA; MO; LA; NDS (tier 5) |
| INFLIXIMAB / REMICADE | PA; MO; QL (20 per 28 days) |
| SKYRIZI (IV) | PA; MO; QL (30 per 180 days); NDS |
| REPATHA / REPATHA SURECLICK | PA; QL (6 per 28 days) |
FAQs
Q: How do I request a formulary exception? A: You or your prescriber should contact the plan to request a tiering or coverage exception; the prescriber must explain the medical reasons why the exception is needed. The plan generally decides within 72 hours of receiving the prescriber's supporting statement; an expedited (fast) decision (within 24 hours) is available if the member’s health could be seriously harmed by waiting.
Q: Will I get notice if my drug is removed mid‑year? A: When the plan makes mid‑year changes that affect members (removals, added restrictions, tier increases), affected members will be notified at least 30 days before the change becomes effective. Alternatively, when a member requests a refill they may receive a 30‑day supply of the drug and written notice of the change.
Clinical Evidence / Rationale
This Drug List / index is a formulary and navigation tool and does not present clinical trial or trial‑level evidence metrics. There are no trial‑level evidence items listed in this part; the document focuses on covered Part D products, tiers, and utilization management controls rather than primary clinical‑trial data.
Revision History
Formulary updated on 04/01/2026; updates are posted monthly to the plan website and reflected as current as of 04/01/2026.
This part of the drug list indicates the drug list was last updated on 03/13/2026; last updated date appears repeatedly with no other revision history in this part.
Describes immediate changes for generics/biosimilars, removals, and member notice/exception rights; when drugs are removed or restrictions added members are notified at least 30 days before the change or provided a 30-day supply at refill per Medicare rules.
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