CareSource Drug Formulary Update: Coverage & PA

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.

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.

Requirements / Limits taxonomy: PA (Prior Authorization) - coverage requires prior authorization when listed

PA defined in table legend

Requirements / Limits taxonomy: MO (Mail‑Order / Medical Override) - mail‑order availability or medical review/override handling when listed

MO defined in table legend

Requirements / Limits taxonomy: LA (Limited Access) - drug may be available only at certain pharmacies or limited distribution when listed

LA defined in table legend

Actions Required by Providers

Prior Authorization

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).

Documentation Required

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.

Applicable Codes & Formulary Abbreviations

Formulary Abbreviations / Requirement Codesmixed

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

Example Drug Tier and Restrictions (selected entries)mixed

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

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Drug entries with PA requirementmixed

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

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Drugs with QL specifiedmixed

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-restricted productsNDC

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

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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.

Vaccine / Miscellaneous entriesmixed

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)

Diabetes/insulin devices and productsmixed

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

High-impact specialty agents with PAmixed

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

2026-04-01Formulary updatedLatest

Formulary updated on 04/01/2026; updates are posted monthly to the plan website and reflected as current as of 04/01/2026.

2026-03-13Part last updated

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.

mid-year (as needed)Mid-year changes / member notice

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CareSource Dual Advantage Plus Formulary (Drug List)

Coverage Summary

Requirements & Limits (PA, QL, ST, NDS, LA)

Actions Required by Providers

Applicable Codes & Formulary Abbreviations

Background & Definitions

Formulary Entries & Examples

FAQs

Clinical Evidence / Rationale

Revision History