CareSource formulary coverage & PA update

Coverage Summary

This part contains the body-system organized list of best-cost options. It is intended to help providers and members choose effective, lower-cost drugs first. The list is not exhaustive of all covered drugs. If a specific brand or generic is not listed here, check the online formulary or contact Member Services.

Prior Authorization / Exception Process

Prior Authorization / Exception Process — criteria for when PA or an exception is required and how requests are handled.

ALL of the following

A prior authorization (PA) is required when the Formulary indicates 'PA' next to a drug name. Examples include high-cost specialty drugs, certain injectables, or drugs with safety/abuse potential.
Providers must submit clinical documentation to support medical necessity when requesting PA or an exception. Typical documentation includes diagnosis, prior therapies tried (including dates and responses), and any relevant labs or clinical notes.
Decision timelines
- Standard PA decisions: CareSource will issue a decision no later than 72 hours after receipt of a complete request.
- Expedited/urgent requests: If the member is suffering from a serious health condition, a decision will be provided within 24 hours of receipt.
If CareSource denies a PA or an exception request, the member and provider will be notified with information about how to appeal the decision.
Requests may be submitted by phone or fax: Providers may call 1-855-852-5558 (follow prompts) or fax 1-866-930-0019. Members or representatives may request exceptions via Member Services at 1-833-230-2099 (TTY/TDD: 1-800-648-6056 or 711).
Operational note: If a therapeutically equivalent, lower-cost alternative on the Formulary is available and clinically appropriate, CareSource will generally not approve an exception for a higher-cost drug.
PA flags shown in the Formulary indicate where prior approval is required; absence of a PA flag generally indicates no prior authorization is required for that product.

Quantity Limits and Step Therapy

Quantity Limits and Step Therapy — criteria logic used to enforce quantity limits (QL) and step therapy (ST) requirements.

ALL of the following

Quantity Limits (QL): When the Formulary lists a QL next to a drug, the Plan limits the amount covered per defined time period (for example, 'QL (2 EA per 30 days)' or 'QL (10 EA per 1 FILL)'). Claims exceeding the QL may require PA or be denied.
Step Therapy (ST): When the Formulary lists 'ST' for a drug, the member must first try specified lower-cost alternative(s) listed on the Formulary before the Plan will cover the requested drug, unless a documented medical reason justifies an exception.
Operational rules
- PA may be required to override a QL or ST requirement; when submitting for override, include clinical rationale and prior therapy documentation.
- For opioid analgesics and selected agents, state regulations and manufacturer dosing recommendations may impose additional quantity limits; check the drug entry for the specific QL.

Coverage Restrictions & Limits (by product examples)

Formulary items with restrictions/limits

Formulary entries include Tier and Restrictions/Limits (PA, ST, QL). Selected nested examples preserve grouped items across categories: psychotropic, movement-disorder agents, diabetes devices, COVID tests, etc.

Psychotropic and movement disorder examples

Antidepressants/SSRIs examples: fluoxetine tablets/capsules have entries showing ST and/or QL values (e.g., fluoxetine tablet 10 mg = ST; QL 30 EA per 30 days; fluvoxamine ER = ST; QL 60 EA per 30 days).
VMAT2 inhibitors / movement disorder agents: AUSTEDO and tetrabenazine entries show PA and QL (e.g., AUSTEDO 12 mg/9 mg PA; QL 120 EA per 30 days; tetrabenazine PA; QL specified).

Wakefulness-promoting agents: aromodafinil/modafinil and WAKIX are listed with PA and QL (e.g., armodafinil PA; QL 30 EA per 30 days; WAKIX PA; QL 30–60 EA per 30 days).

Initial Therapy Criteria

Continuation Therapy Criteria

Continuation / Maintenance (ongoing PA and QL examples)

Continuation/maintenance and ongoing coverage rules where ongoing PA or quantity limits over time apply (examples: specialty biologics, injectables, syringes, lancets, insulin volumes, and recurring QL timeframes).

Ongoing PA for specialty/maintenance agents

Biologics maintenance PA/QL: Many specialty biologics require ongoing prior authorization for continued coverage (examples: HUMIRA, ENBREL, STELARA, TREMFYA, ACTEMRA) and have recurring QL periods (e.g., syringes or ML per 28/30/84 days).
Routine maintenance QLs (per timeframe): Quantity limits are specified per timeframe for ongoing fills (examples: REPATHA 2 injections per 28 days; insulin volumes like 45 mL per 30 days for BASAGLAR; lancets 204 EA per 30 days; syringes 400 EA per 30 days; many biologic QLs per 28/30/84 days).

Device lifetime or interval limits:

Unproven / Exclusions

When exceptions will generally NOT be approved

Branches that describe when exceptions will generally not be approved.

Exception denials — alternative equally effective on formulary: CareSource generally will not approve an exception if an alternative drug on the formulary would be just as effective and would not cause other health problems.

Applicable Codes & Formulary Entries

Formulary Drug Entries - SelectedNDCCovered

hydroxyzine hcl oral solution 10 mg/5 ml	Hydroxyzine HCl oral solution 10 mg/5 mL
metronidazole vaginal 0.75% (37.5 mg/5 gram) gel	Metronidazole vaginal gel 0.75% (37.5 mg/5 g)
metronidazole topical gel 0.75%	Metronidazole topical gel 0.75%
tobramycin in 0.225% nacl	Tobramycin in 0.225% NaCl
tobramycin sulfate injection solution 40 mg/ml	Tobramycin sulfate injection solution 40 mg/mL
PAXLOVID ORAL TABLETS, DOSE PACK 150-100 MG	Paxlovid oral tablets, dose pack 150 mg/100 mg
PAXLOVID ORAL TABLETS, DOSE PACK 300 MG (150 MG X2)-100 MG	Paxlovid oral tablets, dose pack 300 mg (150 mg x2) + 100 mg
FIRVANQ ORAL RECON SOLN 25 MG/ML	Firvanq oral reconstitution solution 25 mg/mL
FIRVANQ ORAL RECON SOLN 50 MG/ML	Firvanq oral reconstitution solution 50 mg/mL
vancomycin oral recon soln 25 mg/ml	Vancomycin oral reconstitution solution 25 mg/mL

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Device & Supply Lists - Diabetes & Injection SuppliesmixedCovered

MONOJECT SYRINGE multiple sizes	Monoject syringes (multiple sizes)
OPTICHAMBER various masks	OptiChamber spacers (various masks)
PEDIATRIC MASK various	Pediatric masks (various sizes)
PRO COMFORT LANCET / SAFETY LANCET	Pro Comfort lancet / safety lancet
PRO COMFORT SPACER / PROCARE SPACER adult/child	Pro Comfort / ProCare spacers (adult and child)
PRODIGY LANCING DEVICE / PRODIGY TWIST TOP LANCET	Prodigy lancing device and twist-top lancets
PURE COMFORT LANCETS / SAFETY LANCETS	Pure Comfort lancets / safety lancets
RELIAMED LANCET 28 GAUGE / 30 GAUGE	ReliaMed lancets 28G and 30G
RIGHTEST GDSOO / GL3OO LANCETS / DEVICES	Rightest GDSOO / GL300 lancets and devices
SAFESNAP SYRINGE multiple sizes	SafeSnap syringes (multiple sizes)

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Diagnostic & Test Strips / Reagent StripsmixedCovered

KETONE CARE / KETONE URINE TEST / KETOSTIX / TRUEPLUS KETONE	Ketone urine test strips (Ketostix, TruePlus)
BIOGLO / GLOSTRIPS OPHTHALMIC	Bioglo / Glostrips ophthalmic strips
DIASTIX / URINE/FECES reagent strips / MULTISTIX / CHEMSTRIP / COMBISTIX	Urine and feces reagent strips (Diastix, Multistix, Chemstrip, CombiStix)

Electrolyte / GI / Miscellaneous AgentsmixedCovered

ENULOSE / GENERLAC / lactulose oral solution	Lactulose oral solutions (Enulose, Generlac)
DEX4 GLUCOSE products / dextrose oral gel / GLUCO BURST / GLUCOSE GEL / glucose oral tablet	Dextrose/glucose oral gels and tablets (Dex4, GlucoBurst)
GLUTOSE 15/45/5	GluTose oral glucose products (15 g, 45 g, 5 g forms)
ELIXOPHYLLIN / THEO-24 / theophylline	Theophylline formulations (Elixophyllin, Theo-24)
IRRIGATING SOLUTIONS AQUASTAT, BD POSIFLUSH, DELFLEX, EXTRANEAL, GLYCINE UROLOGIC	Irrigating solutions including Aquastat, BD Posiflush, DelFlex, Extraneal, glycine urologic
NEBUSAL	Nebusal (bronchodilator solution)

Renal, Electrolyte & Mineral BindersmixedCovered

AURYXIA / AURYXIA _75	Auryxia (ferric citrate) formulations
calcium acetate / lanthanum / sevelamer / VELPHORO	Phosphate binders: calcium acetate, lanthanum, sevelamer, Velphoro
POTASSIUM-REMOVING AGENTS KIONEX, SPS	Potassium removing agents (Kayexalate/SPS, Kionex)
POTASSIUM-SPARING DIURETICS amiloride, triamterene combos	Potassium-sparing diuretics and combinations
Replacement preparations KLOR-CON, EFFER-K	Potassium replacement preparations (Klor-Con, Effer-K)

Prenatals, Contraceptives & Emergency ContraceptionmixedCovered

PRENATAL ONE DAILY / PRENATAL COMPLETE / ONE DAILY PRENATAL	Prenatal vitamins and formulations
AFTER PILL / AFTERA / ella / PLAN B ONE-STEP / OPCICON ONE-STEP / ECONTRA ONE-STEP	Emergency contraceptives including ella, Plan B One-Step and generics
many contraceptives CAMRESE / CAMRESE LO / numerous brand entries	Various contraceptive products and brands

Insulins & AntidiabeticsmixedCovered

glucagon hcl injection recon soln mg/mL	Glucagon HCl injection emergency kits and reconstitution solutions
HUMULIN R REGULAR U-100 INSULIN	Humulin R Regular U-100 insulin
insulin aspart	Insulin aspart (various pens/solutions)
insulin lispro	Insulin lispro (various preparations)
NOVOLIN 70/30 U-100 INSULIN and FlexPen	Novolin 70/30 U-100 insulin and FlexPen
SYNJARDY XR multiple strengths	Synjardy XR combination oral antidiabetic tablets
metformin 500/850/1000 mg	Metformin oral tablets (500 mg, 850 mg, 1000 mg)
glyburide-metformin 2.5-500 mg / 5-500 mg	Glyburide-metformin combination tablets

Anti-infectives & HIV-relatedNDCCovered

AZASITE / azithromycin	Azithromycin ophthalmic (AzaSite) and oral formulations
azathioprine	Azathioprine
DESCOVY ORAL TABLET 120-15 MG (alt line)	Descovy alternative listing (120 mg/15 mg noted)
TREMFYA / TREMFYA PEN	Tremfya and pen formulations
glatiramer 20 mg/mL & 40 mg/mL / GLATOPA	Glatiramer formulations including Glatopa
mycophenolate mofetil / mycophenolate sodium	Mycophenolate agents

Provider Actions & How to Comply

Prior Authorization

Prior Authorization submission

Submit prior authorization (PA) requests by phone or fax. Providers should call 1-855-852-5558 (follow prompts) or fax requests to 1-866-930-0019. If CareSource receives the request before 5 p.m. on Friday a decision will be provided within 24 hours; requests received on weekends or most holidays may take longer.

Documentation Required

Exception clinical documentation

When CareSource requests clinical documentation for an exception, the health partner must provide written clinical information. CareSource will decide on exception requests no later than 72 hours after receipt (or within 24 hours for serious health conditions). Member or representative can request exceptions online or via Member Services at 1-833-230-2099 (TTY/TDD: 1-800-648-6056 or 711).

Clinical Evidence & Notes

Formulary design emphasizes listing best-cost options with generics preferred where available; generics are safe, effective and generally lower cost. The Formulary may change at any time as new drugs become available or become generic. No clinical trial evidence or metric cards are provided in this part.

Background & Definitions

CareSource’s Part 1 Drug Formulary is organized by body system or condition and lists best-cost options; generics are preferred and shown in lowercase italics while brand names are shown in ALL CAPS. Part 1 contains the therapeutic-category listings; an alphabetical index for quick reference is provided in Part 2. The Formulary entries include tier assignment (0–4) and any Requirements/Limits (PA = prior authorization, ST = step therapy, QL = quantity limits). The Formulary can change at any time.

Definitions: PA — Prior Authorization: approval required before the member can fill the prescription. QL — Quantity Limit: the amount of the drug the Plan will cover in the specified time frame. ST — Step Therapy: requirement to try specified drugs first before covering another drug. AR — Age Restriction: coverage limited to certain age ranges without PA. OTC — Over-the-Counter: non-prescription drug. Tier — Formulary cost-sharing tier assignment (Tier 0–4).

Quantity-limit (QL) thresholds and document date (examples)

Formulary current dateCURRENT AS OF 10/1/2024

Common syringe quantity limit (example)QL (400 EA per 30 days)

Common lancet quantity limit (example)QL (204 EA per 30 days)

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Your Guide to Best-Cost Options