CareSource Prior Authorization Lookup
Latest CareSource prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Adzynma (ADAMTS13, recombinant-krhn) — Medical prior authorization and coverage criteria for congenital TTPDefines medical prior authorization and coverage criteria for Adzynma used as prophylactic or on‑demand enzyme replacement therapy in adult and pediatric patients with congenital thrombotic thrombocytopenic purpura (cTTP) for CareSource Arkansas PASSE.All CareSource updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-07-01Medical Benefit Drugs administrative policyGoverns prior authorization, documentation, site-of-care, and reauthorization requirements for medications billed to the medical benefit for CareSource members (Arkansas PASSE context). Affects providers requesting coverage for medical benefit medications.All CareSource updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Genetic Testing and Counseling - Arkansas PASSEGoverns prior authorization, medical necessity review, and genetic counseling requirements for germline and somatic genetic testing for CareSource members in the Arkansas PASSE program.All CareSource updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Revisional Metabolic and Bariatric Surgery (Coverage Criteria)Defines medical necessity and coverage criteria for revision bariatric procedures for CareSource Arkansas PASSE members, including indications, exclusions, required documentation, and prior authorization requirements.All CareSource updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-01List of Covered Drugs (Drug List) — CareSource MyCare OhioCareSource MyCare Ohio formulary describing covered drugs, utilization controls (prior authorization, quantity limits, step therapy), and member/provider processes for exceptions and temporary supplies.All CareSource updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01CareSource Dual Advantage Formulary (Drug List) — Coverage CriteriaDescribes 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.All CareSource updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01CareSource Dual Advantage Plus Formulary (Drug List)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.All CareSource updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Evkeeza (evinacumab-dgnb) — Coverage Criteria for Homozygous Familial Hypercholesterolemia (HoFH)This policy governs prior-authorization medical benefit coverage of Evkeeza (evinacumab-dgnb) for members with homozygous familial hypercholesterolemia (HoFH) in Arkansas PASSE. It describes initial and reauthorization clinical criteria, required documentation, dosing, and coverage stance.All CareSource updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01HAP CareSource MI Coordinated Health List of Covered Drugs (Drug List)This document is the Plan's List of Covered Drugs (Drug List) for HAP CareSource MI Coordinated Health describing covered drugs, restrictions (prior authorization, quantity limits, step therapy), member rights (exceptions, transitions), pharmacy supply options (mail-order, retail), and FAQs. It applies to plan members using network pharmacies and explains rules for Medicare and Michigan Medicaid covered drugs.All CareSource updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Multiple drug-specific prior authorization criteria (Part 1 of 17)Part of a multi-part CareSource drug prior authorization policy listing numerous medical-benefit drugs with indication-specific prior authorization criteria, exclusions, required information, age and prescriber restrictions, and coverage durations.All CareSource updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Oncology treatment regimen review via Eviti ConnectDefines prior authorization and review requirements for oncology treatment regimens submitted through the NantHealth Eviti Connect portal and applies to oncology drug regimens covered under the pharmacy/oncology benefit for CareSource members in Arkansas PASSE.All CareSource updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Palsonify (paltusotine) — Coverage Criteria (Arkansas PASSE)Defines prior authorization requirements and coverage criteria for Palsonify (paltusotine) for adult members with acromegaly under the pharmacy benefit for CareSource Arkansas PASSE.All CareSource updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Papzimeos (imadenovec-drba) — Coverage and Prior Authorization CriteriaDefines prior authorization, coverage criteria, and limits for Papzimeos (imadenovec-drba) as a medical benefit for adults with recurrent respiratory papillomatosis (RRP) in the payer's Arkansas PASSE program.All CareSource updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Skysona (elivaldogene autotemcel) — Prior authorization and coverage criteriaDefines prior authorization and medical necessity criteria for Skysona (elivaldogene autotemcel) as a one-time gene therapy for boys 4–17 years with early, active cerebral adrenoleukodystrophy (CALD); applies to the payer's pharmacy/medical benefit in Arkansas PASSE and affects prescribers and prior authorization reviewers.All CareSource updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Tocilizumab (Actemra) and related biologic prior authorization criteriaDefines prior authorization, coverage, exclusions, age and prescriber restrictions, and required documentation for intravenous and subcutaneous formulations of tocilizumab (Actemra) and related biologic products for CareSource members in North Carolina.All CareSource updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Zevaskyn (prademagene zamikeracel) coverage for RDEB woundsThis pharmacy policy governs prior-authorization medical coverage of Zevaskyn (autologous gene-modified cell-sheet therapy) for treatment of wounds in adult and pediatric members with recessive dystrophic epidermolysis bullosa (RDEB) in the payer's Arkansas PASSE program.All CareSource updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-01List of Covered Drugs (Drug List) — Formulary and Utilization ControlsDescribes the drugs, OTC items, and non-drug products covered by HAP CareSource MI Coordinated Health, including rules (prior authorization, quantity limits, step therapy) and how members/providers can request exceptions or find covered drugs.All CareSource updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-01Sacroiliac Joint Procedures — SIJ injections and radiofrequency ablation (RFA)Defines medical necessity, limitations, and requirements for diagnostic and therapeutic sacroiliac joint (SIJ) injections and SIJ radiofrequency ablation (RFA) for Arkansas PASSE members; applies to providers requesting coverage and prior authorization.All CareSource updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-01Tocilizumab (Actemra) and selected specialty injectable medication coverageClinical prior authorization and coverage criteria for Actemra (intravenous and subcutaneous formulations) and summary entries for other specialty products listed in this section; governs CareSource members in North Carolina and providers seeking prior authorization for these products.All CareSource updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-01-011915(c) HCBS fee schedule, prior authorization and invoice requirements — ArkansasDefines covered HCBS service codes, modifiers, units, fee schedules, prior authorization and invoice requirements for CareSource members in Arkansas under the 1915(c) program effective January 1, 2026.All CareSource updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-01-01Certificate of Coverage (CareSource) — Terms, Conditions, Exclusions, and Limitations of CoverageGoverns the terms, conditions, exclusions, and limitations of CareSource health insurance coverage for covered persons, including in‑network requirements, prior authorization rules, and member rights and responsibilities.All CareSource updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-01-01Certificate of Coverage — CareSourceGoverns the terms, conditions, exclusions, and limitations of CareSource insurance coverage for enrolled members, including how to obtain benefits, network requirements, and prior authorization rules.All CareSource updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Fractional Flow Reserve from Computed Tomography (FFRct)Medical policy governing use, prior authorization, and procedure limitations for noninvasive HeartFlow FFRct testing to evaluate coronary artery disease in symptomatic, clinically stable members; applies to CareSource members in Arkansas PASSE program.All CareSource updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Fractional Flow Reserve from Computed Tomography (FFRct)Defines prior authorization, clinical eligibility, and procedural limitations for noninvasive Heartflow FFRct testing for members with suspected or known coronary artery disease in the Arkansas PASSE population.All CareSource updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-01-01Individual & Family Plan Certificate of Coverage (Wisconsin)This document is the Certificate of Coverage for CareSource (Common Ground Healthcare) Individual & Family Marketplace plans offered in Wisconsin, describing benefits, limitations, member rights/responsibilities, prior authorization requirements, network rules, and how to obtain covered services for enrolled members.All CareSource updates
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Tool Description
Search CareSourceprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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Prior auth requirements change all the time. Keep up with every payer policy update in the live policy feed, or browse payers with prior authorization policies.
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