Claims Payment System ic Errors (CPSE) Update Report Confidential and Proprietary As of: June 15, 2026 Listed below are current CPSE. This log is updated monthly. Please review this log for CPSE updates on status, target dates for reprocessing and resolutions. If you have questions after reviewing the log, please call Provider Services at 1-8 00-488-0134. Unique ID and Description of CPSE Line of Business Date CPSE was First Identified Billing Provider Type(s) Impacted by CPSE (select all that apply) Timeline for Fixing CPSE Date(s) and/or Date Span(s) of Corrected Claims Adjustments CPSE Status Unique ID CSO0686774:Confirmed CPSEBehavioral Health claims billed with diagnosis codes (See Below) denied 9NP (Service not payable for provider), XIR (Invalid diagnosis code submitted) and XPS (Service not payable for provider) and should pay. This is a potential underpayment to claims.Codes Included:F1090,F1091,F1191,F1291,F1491,F4381,F4389 Medicaid 1/23/2026 37-Licensed Independent Social Worker (LISW)42-Psychologist, Individual53-Behavior Analyst84-Ohio Department of Mental Health (Community Mental Health) Provider95-ODADAS Certified/Licensed (SUD) Treatment Program96-Paraprofessional 3/12/20263/23/20264/9/20264/22/20264/20/2026 Target Claims reprocessing date 6/4/2026-6/11/2026Target Claims reprocessing date 6/16/2026-6/23/2026 In Process Unique ID CSO069744:Confirmed CPSEOhio Department of Medicaid (ODM) direction received that Rehabilitation, Long term acute care (LTAC), and Cancer hospitals that reimburse at cost to share ratio (CCR) shall have payment of 90% or 91.7% of CCR. This is a potential overpayment/underpayment to claims. Medicaid 1/29/2026 01-Hospital (Inpatient) 2/19/20262/26/20262/25/20264/23/2026 Target Claims reprocessing date 5/21/2026-5/28/2026Claims reprocessed on 5/12/2026 Completed Unique ID CSO0697235:Confirmed CPSEEffective 1/1/2026 vision claims billed with diagnosis codes (see below) paid and should have denied to submit claims to EyeMed. This is a potential overpayment to claims. Codes included:H52.00, H52.01, H52.02, H52.03, H52.10, H52.11, H52.12, H52.13, H52.201, H52.202, H52.203, H52.209, H52.211, H52.212, H52.213, H52.219, H52.221, H52.222, H52.223, H52.229, H52.31, H52.32, H52.4, H52.521, H52.522, H52.523, H52.529, H52.531, H52.532, H52.533, H52.539, H52.6, H52.7, H53.141, H53.142, H53.143, H53.149, H53.50, Z01.00, Z01.01, Z01.020, Z01.021, Z46.0, Z97.3 Medicaid & MyCare 3/9/2026 20-Physician/Osteopath, Individual35-Optometrist, Individual75-Optician 4/13/20264/20/20264/13/20264/15/2026 Target Claims reprocessing date 5/11/2026-5/18/2026Claims reprocessed on 5/18/2026 Completed Unique ID CSO0723827:Confirmed CPSENot CPSEProfessional claims billed with procedure code S5136 (Companion care, adult (e.g., IADL/ADL); per diem) paid without an authorization and should have denied. This is a potential overpayment to claims MyCare 3/26/2026 45-Waivered Services Organization55-Waivered Services, Individual 4/16/20264/15/2026 Target Claims reprocessing date 5/14/2026-5/21/2026 Removed from log Unique ID CSO0715872:Confirmed CPSEProfessional claims were being reimbursed from the Qualified Provider Fee Schedule and should have been reimbursed from the CMS Physician Resource-Based Relative Value Scale Fee schedule. This is a potential overpayment/underpayment to claims. MyCare 3/27/2026 20-Physician/Osteopath, Individual 4/29/20265/4/20265/6/2026 Target Claims reprocessing date 5/20/2026-5/27/2026Target Claims reprocessing date 6/16/2026-6/23/2026 In Process Unique ID CSO0714121:Confirmed CPSEProfessional claims billed with procedure code 90785 "Interactive complexity (List separately in addition to the code for primary procedure)" denied Z50 (Medicare Non-Covered Service) and should pay. This is a potential underpayment to claims. MyCare 3/27/2026 20-Physician/Osteopath, Individual37-Licensed Independent Social Worker (LISW)52-Independent Marriage and Family Therapist54-Licensed Independent Chemical Dependency Counselor72-Nurse Practitioner, Individual 4/15/20264/11/2026 Target Claims reprocessing date 5/11/2026-5/18/2026Claims reprocessed on 5/14/2026 Completed Unique ID CSO0732140:Confirmed CPSEOutpatient Facility Renal claims were reimbursed at an old contracted rate and should have been reimbursed at the amended contractual rate effective 2/1/2026. This is a potential overpayment/underpayment to claims. Medicaid & MyCare 4/7/2026 59-End-Stage Renal Disease (Dialysis) Clinic 5/1/20265/28/20266/4/20266/11/20266/10/2026 Target Claims reprocessing date 6/25/2026-7/2/2026Target Claims reprocessing date 7/2/2026-7/9/2026 In Process Unique ID CSO0725940:Confirmed CPSEHospice claims billed with procedure codes T2042 (Hospice routine home care; per diem) and T2043 (Hospice continuous home care; per hour) and not billed with the Value code 61 paid and should have denied. Procedure codes T2044 (Hospice inpatient respite care; per diem) and T2045 (Hospice general inpatient care; per diem) billed without the Value code G8 paid and should have denied. This is a potential overpayment to claims. Medicaid & MyCare 4/9/2026 44-Hospice 5/6/20265/7/20265/14/20265/21/20265/14/2026 Target Claims reprocessing date 6/3/2026-6/10/2026Target Claims reprocessing date 6/17/2026-6/24/2026 In Process Unique ID CSO0696875:Confirmed CPSEProfessional claims billed with procedure code T1019 Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant) and T1001 Nursing assessment/evaluation together on the same claim paid and the entire claim should have denied. This is a potential overpayment to claims. MyCare 4/15/2026 45-Waivered Services Organization55-Waivered Services, Individual 5/6/2026 Target Claims reprocessing date 6/3/2026-6/10/2026Claims reprocessed on 6/10/2026 Completed Unique ID CSO0741447:Confirmed CPSEGenetic testing procedure codes (see below) denied X94 (Service requires authorization) and should pay. This is a potential underpayment to claims. Genetic testing procedure code 81381 paid and should have denied for no authorization. This is a potential overpayment to claims. Codes included:81220, 81335, 81401 Medicaid & MyCare 4/21/2026 80-Independent Laboratory 5/18/2026 Target Claims reprocessing date 6/15/2026-6/22/2026 Claims reprocessed on 6/9/2026 Completed Unique ID CSO0702213:Confirmed CPSEProcedure codes A4453 "Rectal catheter with or without balloon, for use with any type transanal irrigation system, each" and B4104 "Additive for enteral formula (e.g., fiber)" denied X99 (Not a covered service/procedure) and should have paid as of 1/1/26. This is a potential underpayment to claims. Medicaid & MyCare 4/29/2026 76-Durable Medical Equipment Supplier 5/28/20265/27/2026 Target Claims reprocessing date 6/25/2026-7/2/2026 In Process Unique ID CSO07414985:Confirmed CPSEInpatient lab codes (see below) paid without applying member responsibility. This is a potential overpayment to claims. Codes included:80503, 80504, 80505, 80506, ,81599, 83020, 84165, 84166, 85576, 85390, 86255, 86320, 86325, 86334, 86335,88104, 88106, 88108, 88112, 88120, 88121, 88125, 88141, 88160, 88161, 88162, 88172, 88173, 88177, 88199, 88300, 88302, 88304, 88305, 88307, 88309, 88311, 88312, 88313, 88314, 88319, 88321, 88323, 88325, 88329, 88331, 88332, 88333, 88334, 88346, 88348, 88350, 88362, 88363, 88375, 88380, 88381, 88387, 88388, 88399, 89240, G0416, G0452 MyCare 5/1/2026 20-Physician/Osteopath, Individual 6/2/20266/3/20266/1/20265/27/2026 Target Claims reprocessing date 6/30/26-7/7/2026 In Process Confidential and Proprietary Unique ID and Description of CPSELine of BusinessDate CPSE was First IdentifiedBilling Provider Type(s) Impacted by CPSE (select all that apply)Timeline for Fixing CPSEDate(s) and/or Date Span(s) of Corrected Claims Adjustments CPSE StatusUnique ID CSO0710826:Confirmed CPSEBehavioral Health claims billed with place of service 2 and 10 denied 4SW (Disallow Verify place of service) when crossed over to Medicaid and should pay. This is a potential underpayment to claims. MyCare5/11/202620-Physician/Osteopath, Individual24-Physician Assistant37-Licensed Independent Social Worker (LISW)42-Psychologist, Individual47-Professional Clinical Counselor54-Licensed Independent Chemical DependencyCounselor72-Nurse Practitioner, Individual 5/13/2026 5/14/20265/19/2026Target Claim reprocessing date 6/29/26-7/6/2026In ProcessUnique ID CSO0729158:Confirmed CPSECorrected claims that denied for timely filing recovered previous payment from the original claim and should not have. This is a potential underpayment to claims. Medicaid 5/15/2026 00-All provider types6/2/2026 Target Claims reprocessing date 6/30/2026-7/6/2026 In ProcessUnique ID CSO0722311:Confirmed CPSE Professional claims billed with procedure code T1001 (Nursing assessment/evaluation) by two different providers within a 60 day period denied 181 (Disallow exceeds maximum number of units) and should pay. This is a potential underpayment to claims. Medicaid & MyCare 5/15/2026 16 & 60-Home Health Agency6/11/2026 Target Claims reprocessing date 7/9/2026-7/16/2026 In ProcessUnique ID TFS1742869:Confirmed CPSEProfessional claims billed with procedure codes (see below) and a GT modifier denied p08 (Required modifier is missing or invalid) and should pay. This is a potential underpayment to claims.Codes included:97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T Medicaid & MyCare 5/15/2026 53-Behavior Analyst 5/18/2026 Target Claims reprocessing date 7/2/2026-7/9/2026 In ProcessUnique ID CSO0722714:Confirmed CPSEProfessional claims billed with procedure codes (see below) denied X99 (Not a covered service/procedure) and should pay. This is a potential underpayment to claims. Codes included:90662, 98966, 98967, 98968, 99070, 99173, 99291, 99292, 99408, G0008, G0179, G0180, G0404, G0426, G0427, L3935, S5136 Medicaid & MyCare 5/18/202620-Physician/Osteopath, Individual24-Physician Assistant 6/29/2026Target Claims reprocessing date 7/25/2026-8/2/2026In ProcessUnique ID CSO0761306:Confirmed CPSEProfessional claims billed with procedure codes 90791 (Psychiatric diagnostic evaluation) and 90792 (Psychiatric diagnostic evaluation with medical services) denied Z50 (Medicare Non-Covered Service) and should pay. This is a potential underpayment to claims. MyCare5/28/202620-Physician/Osteopath, Individual37-Licensed Independent Social Worker (LISW)42-Psychologist, Individual47-Professional Clinical Counselor52-Independent Marriage and Family Therapist54-Licensed Independent Chemical DependencyCounselor72-Nurse Practitioner, Individual 7/8/2026 Target Claims reprocessing date 8/5/2026-8/12/2026In ProcessUnique ID CSO0752974:Confirmed CPSEBehavioral health claims billed with diagnosis (see below) denied 41R (Disallow Invalid ICD9/10-CM diagnosis) and should pay. This is a potential underpayment to claims. Codes included:F50010, F50011, F50019, F50020, F50021, F5022, F50811, F50812, F5089 Medicaid & MyCare 5/29/202620-Physician/Osteopath, Individual24-Physician Assistant37-Licensed Independent Social Worker (LISW)96-Paraprofessional47-Professional Clinical Counselor72-Nurse Practitioner, Individual 7/9/2026 Target Claims reprocessing date 8/21/2026-8/28/2026In ProcessUnique ID CSO0759797:Confirmed CPSEProfessional claims billed with procedure codes (see below) for Out of Network providers with place of service 31, 32 and 33 paid and should deny PA required-non par provider. This is a potential overpayment to claims. Codes included:36415, 70110, 70140, 70150, 70360, 71045, 71046, 71100, 71101, 71110, 72020, 72040, 72050, 72070, 72083, 72100, 72120, 72170, 72220, 73000, 73020, 73030, 73060, 73070, 73080, 73090, 73100, 73110, 73120, 73130, 73140, 73502, 73503, 73521, 73522, 73551, 73552, 73560, 73562, 73564, 73590, 73600, 73610, 73620, 73630, 73660, 74018, 74019, 76514, 76536, 76604, 76642, 76700, 76705, 76770, 76775, 76856, 76857, 76870, 76882, 93000, 93005, 93010, 93306, 93308, 93880, 93922, 93925, 93926, 93970, 93971, 93975, P9603, P9604, Q0092, R0070, R0075 Medicaid & MyCare 6/1/2026 20-Physician/Osteopath, Individual24-Physician Assistant80-Independent Laboratory 7/23/2026 Target Claims reprocessing date 8/20/2026-8/27/2026In ProcessUnique ID CSO0761191:Confirmed CPSEProfessional claims billed with procedure code 92273 "Electroretinography (ERG), with interpretation and report; full field (ie, ffERG, flash ERG, Ganzfeld ERG)" denied Z50 (Medicare Non-Covered Service) and should pay. This is a potential underpayment to claims. MyCare6/4/2026 35-Optometrist, Individual 7/24/2026 Target Claims reprocessing date 8/21/2026-8/28/2026 In Process Confidential and ProprietaryOH-Multi-P-5697451
Pharmacy Policy Updates June 2026The following policies are effective July 1, 2026CareSource Dual Advantage (HMO D-SNP) CareSource Dual Advantage Plus (HMO D-SNP) 2 Y0119_GA-SNP-P -5691354_C | Policy Updates Network Notification | June 2026AT CARESOURCE, WE LISTEN TO OUR PROVIDERS, AND WE STREAMLINE OUR BUSINESS PRACTICES TO MAKE IT EASIER FOR YOU TO WORK WITH US. We have worked to create a predictable cycle for releasing administrative, pharmacy, and reimbursement policies, so you know wha t to expect.Check back each month for a consolidated network notification of policy updates from CareSource.HOW TO USE THIS NETWORK NOTIFICATION Reference the list of policy updates. Note the effective date and impacted plans for each policy. Click the hyperlinked policy title to open the webpage containing the policy location. FIND OUR POLICIES ONLINETo access all CareSource policies, visit CareSource.com Providers Tools & Resources Provider Policies . Select your plan and state, then Pharmacy, Reimbursement, or Administrative. Each policy page has an archive where you can find previous versions of poli cies. PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACT Kisunla (donanemab-azbt intravenous infusion Lilly)JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Leqembi ( lecanemab-irmb intravenous infusion Eisai/Biogen)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Bildyos (denosumab-nxxp subcutaneousinjection Organon)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Bosaya (denosumab-kyqq subcutaneousinjection Biocon)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Conexxence (denosumab-bnht subcutaneous injection Fresenius Kabi) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION3 Y0119_GA-SNP-P -5691354_C | Policy Updates Network Notification | June 2026 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACT Enoby (denosumab-qbde subcutaneousinjection Hikma)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Jubbonti (denosumab-bbdz subcutaneousinjection Sandoz)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Ospomyv (denosumab-dssb subcutaneous injection Samsung Bioepis ) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Prolia (denosumab subcutaneous injection Amgen JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Stoboclo (denosumab-bmwo subcutaneous injection Celltrion) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION4 Y0119_GA-SNP-P -5691354_C | Policy Updates Network Notification | June 2026 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACT Evenity (romosozumab- aqqg subcutaneous injection Amgen) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Ibandronate intravenous infusion generic JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Reclast (zoledronic acid intravenous infusion Novartis, generic)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Tzield (teplizumab-mzwv intravenous infusion Provention/Sanofi) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Actemra (tocilizumab intravenous infusion Genentech/Roche) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION5 Y0119_GA-SNP-P -5691354_C | Policy Updates Network Notification | June 2026 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACT Avtozma (tocilizumab- anoh intravenous infusion Celltrion) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Tofidence (tocilizumab-bavi intravenous infusion Biogen) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Tyenne (tocilizumab-aazg intravenous infusion Fresenius Kabi)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Spevigo (spesolimab-sbzo intravenous infusion Boehringer Ingelheim) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Orencia (abatacept intravenous infusion Bristol-Myers Squibb) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION6 Y0119_GA-SNP-P -5691354_C | Policy Updates Network Notification | June 2026 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACT Fasenra (benralizumab subcutaneous injection AstraZeneca) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Waskyra (etuvetidigene autotemcel intravenous infusion Fondazione Telethon ETS) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) NEW Supprelin LA (histrelin acetate subcutaneous implant Endo) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Zoladex (goserelin acetate subcutaneous implant TerSera Therapeutics) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Vpriv (velaglucerase intravenous infusion Takeda) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION7 Y0119_GA-SNP-P -5691354_C | Policy Updates Network Notification | June 2026 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACT Elelyso ( taliglucerase intravenous infusion Pfizer) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Elaprase ( idursulfase intravenous infusion Takeda) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Kyprolis (carfilzomib intravenous infusion Amgen/Onyx) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Tecentriq (atezolizumab intravenous infusion Genentech/Roche) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs subcutaneous injection Genentech) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION8 Y0119_GA-SNP-P -5691354_C | Policy Updates Network Notification | June 2026 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACT Opdivo (nivolumab intravenous infusion Bristol-Myers Squibb) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Rybrevant ( amivantamab-vmjw intravenous infusion Janssen) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Imjudo ( tremelimumab-actl intravenous infusion AstraZeneca)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Kebilidi (eladocagene exuparvovec-tneq suspension for intraputaminal infusion PTC Therapeutics) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Stelara (ustekinumab intravenous infusion Janssen Biotech) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION9 Y0119_GA-SNP-P -5691354_C | Policy Updates Network Notification | June 2026 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACTImuldosa (ustekinumab-srlf intravenous infusion Accord) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Otulfi (ustekinumab-aauz intravenous infusion Formycon/Fresenius)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Pyzchiva (ustekinumab-ttwe intravenous infusion Sandoz/Samsung) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Selarsdi (ustekinumab-aekn intravenous infusion Alvotech/Teva)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Starjemza (ustekinumab-hmny intravenous infusion BioThera ) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION10 Y0119_GA-SNP-P -5691354_C | Policy Updates Network Notification | June 2026 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACTSteqeyma (ustekinumab-stba intravenous infusion Celltrion) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Wezlana (ustekinumab-auub intravenous infusion Amgen) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Yesintek (ustekinumab-kfce intravenous infusion Biocon) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Ustekinumab intravenous infusion (Janssen Biotech) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Ustekinumab-ttwe intravenous infusion ( Quallent ) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION11 Y0119_GA-SNP-P -5691354_C | Policy Updates Network Notification | June 2026 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACTImcivree (setmelanotide subcutaneous injection Rhythm) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Empliciti ( elotuzumab intravenous infusion Bristol-Myers Squibb) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Imlygic ( talimogene laherparepvec intralesional injection Amgen/ BioVex ) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Adstiladrin (nadofaragene firadenovec-vncg intravesical suspension Ferring) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Anktiva (nogapendekin alfa inbakicept-pmln intravesical solution ImmunityBio) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION12 Y0119_GA-SNP-P -5691354_C | Policy Updates Network Notification | June 2026 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACT Encelto ( revakinagene taroretcel-lwey intravitreal implant Neurotech) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Otarmeni ( lunsotogene parvec-cwha intracochlear infusion Regeneron) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Vabysmo ( faricimab-svoa intravitreal injection Genentech)JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISIONAvlayah ( tividenofusp alfa-eknm intravenous infusion Denali) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) NEW Oncology (Injectable-CD38-Directed Cytolytic Antibody) – Sarclisa UM Medical Policy JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) NEW13 Y0119_GA-SNP-P -5691354_C | Policy Updates Network Notification | June 2026
Pharmacy Policy Updates June 2026The following policies are effective July 1, 2026HAP CareSource MI Coordinated Health (HMO D-SNP) 2 Policy Updates Network Notification | H4193_MI-SNP-P -5691452_C | June 2026AT HAP CARESOURCE, WE LISTEN TO OUR PROVIDERS, AND WE STREAMLINE OUR BUSINESS PRACTICES TO MAKE IT EASIER FOR YOU TO WORK WITH US. We have worked to create a predictable cycle for releasing administrative, pharmacy, and reimbursement policies, so you know wha t to expect.Check back each month for a consolidated network notification of policy updates from HAP CareSource.HOW TO USE THIS NETWORK NOTIFICATION Reference the list of policy updates. Note the effective date and impacted plans for each policy. Click the hyperlinked policy title to open the webpage containing the policy location. FIND OUR POLICIES ONLINETo access all HAP CareSource policies, visit HAPCareSource.com > Providers > Tools & Resources > Provider Policies . Select your plan and state, then Pharmacy, Reimbursement, or Administrative. Each policy page has an archive where you can find previous versions of policies. PHARMACY POLICY UPDATES3 Policy Updates Network Notification | H4193_MI-SNP-P -5691452_C | June 2026 POLICY NAME EFFECTIVE DATE PLAN IMPACT Kisunla (donanemab-azbt intravenous infusion Lilly)JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Leqembi ( lecanemab-irmb intravenous infusion Eisai/Biogen)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Bildyos (denosumab-nxxp subcutaneousinjection Organon)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Bosaya (denosumab-kyqq subcutaneousinjection Biocon)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Conexxence (denosumab-bnht subcutaneous injection Fresenius Kabi) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION PHARMACY POLICY UPDATES4 Policy Updates Network Notification | H4193_MI-SNP-P -5691452_C | June 2026 POLICY NAME EFFECTIVE DATE PLAN IMPACT Enoby (denosumab-qbde subcutaneousinjection Hikma)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Jubbonti (denosumab-bbdz subcutaneousinjection Sandoz)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Ospomyv (denosumab-dssb subcutaneous injection Samsung Bioepis ) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Prolia (denosumab subcutaneous injection Amgen JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Stoboclo (denosumab-bmwo subcutaneous injection Celltrion) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION PHARMACY POLICY UPDATES5 Policy Updates Network Notification | H4193_MI-SNP-P -5691452_C | June 2026 POLICY NAME EFFECTIVE DATE PLAN IMPACT Evenity (romosozumab- aqqg subcutaneous injection Amgen) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Ibandronate intravenous infusion generic JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Reclast (zoledronic acid intravenous infusion Novartis, generic)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Tzield (teplizumab-mzwv intravenous infusion Provention/Sanofi) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Actemra (tocilizumab intravenous infusion Genentech/Roche) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION PHARMACY POLICY UPDATES6 Policy Updates Network Notification | H4193_MI-SNP-P -5691452_C | June 2026 POLICY NAME EFFECTIVE DATE PLAN IMPACT Avtozma (tocilizumab- anoh intravenous infusion Celltrion) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Tofidence (tocilizumab-bavi intravenous infusion Biogen) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Tyenne (tocilizumab-aazg intravenous infusion Fresenius Kabi)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Spevigo (spesolimab-sbzo intravenous infusion Boehringer Ingelheim) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Orencia (abatacept intravenous infusion Bristol-Myers Squibb) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION PHARMACY POLICY UPDATES7 Policy Updates Network Notification | H4193_MI-SNP-P -5691452_C | June 2026 POLICY NAME EFFECTIVE DATE PLAN IMPACT Fasenra (benralizumab subcutaneous injection AstraZeneca) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Waskyra (etuvetidigene autotemcel intravenous infusion Fondazione Telethon ETS) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) NEW Supprelin LA (histrelin acetate subcutaneous implant Endo) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Zoladex (goserelin acetate subcutaneous implant TerSera Therapeutics) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Vpriv (velaglucerase intravenous infusion Takeda) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION PHARMACY POLICY UPDATES8 Policy Updates Network Notification | H4193_MI-SNP-P -5691452_C | June 2026 POLICY NAME EFFECTIVE DATE PLAN IMPACT Elelyso ( taliglucerase intravenous infusion Pfizer) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Elaprase ( idursulfase intravenous infusion Takeda) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Kyprolis (carfilzomib intravenous infusion Amgen/Onyx) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Tecentriq (atezolizumab intravenous infusion Genentech/Roche) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs subcutaneous injection Genentech) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION PHARMACY POLICY UPDATES9 Policy Updates Network Notification | H4193_MI-SNP-P -5691452_C | June 2026 POLICY NAME EFFECTIVE DATE PLAN IMPACT Opdivo (nivolumab intravenous infusion Bristol-Myers Squibb) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Rybrevant ( amivantamab-vmjw intravenous infusion Janssen) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Imjudo ( tremelimumab-actl intravenous infusion AstraZeneca)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Kebilidi (eladocagene exuparvovec-tneq suspension for intraputaminal infusion PTC Therapeutics) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Stelara (ustekinumab intravenous infusion Janssen Biotech) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION PHARMACY POLICY UPDATES10 Policy Updates Network Notification | H4193_MI-SNP-P -5691452_C | June 2026 POLICY NAME EFFECTIVE DATE PLAN IMPACTImuldosa (ustekinumab-srlf intravenous infusion Accord) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Otulfi (ustekinumab-aauz intravenous infusion Formycon/Fresenius)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Pyzchiva (ustekinumab-ttwe intravenous infusion Sandoz/Samsung) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Selarsdi (ustekinumab-aekn intravenous infusion Alvotech/Teva)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Starjemza (ustekinumab-hmny intravenous infusion BioThera ) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION PHARMACY POLICY UPDATES11 Policy Updates Network Notification | H4193_MI-SNP-P -5691452_C | June 2026 POLICY NAME EFFECTIVE DATE PLAN IMPACTSteqeyma (ustekinumab-stba intravenous infusion Celltrion) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Wezlana (ustekinumab-auub intravenous infusion Amgen) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Yesintek (ustekinumab-kfce intravenous infusion Biocon) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Ustekinumab intravenous infusion (Janssen Biotech) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Ustekinumab-ttwe intravenous infusion ( Quallent ) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION PHARMACY POLICY UPDATES12 Policy Updates Network Notification | H4193_MI-SNP-P -5691452_C | June 2026 POLICY NAME EFFECTIVE DATE PLAN IMPACTImcivree (setmelanotide subcutaneous injection Rhythm) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Empliciti ( elotuzumab intravenous infusion Bristol-Myers Squibb) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Imlygic ( talimogene laherparepvec intralesional injection Amgen/ BioVex ) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Adstiladrin (nadofaragene firadenovec-vncg intravesical suspension Ferring) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Anktiva (nogapendekin alfa inbakicept-pmln intravesical solution ImmunityBio) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION PHARMACY POLICY UPDATES13 Policy Updates Network Notification | H4193_MI-SNP-P -5691452_C | June 2026 POLICY NAME EFFECTIVE DATE PLAN IMPACT Encelto ( revakinagene taroretcel-lwey intravitreal implant Neurotech) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Otarmeni ( lunsotogene parvec-cwha intracochlear infusion Regeneron) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Vabysmo ( faricimab-svoa intravitreal injection Genentech)JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISIONAvlayah ( tividenofusp alfa-eknm intravenous infusion Denali) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) NEW Oncology (Injectable-CD38-Directed Cytolytic Antibody) – Sarclisa UM Medical Policy JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) NEW
Pharmacy Policy Updates June 2026The following policies are effective July 1, 2026CareSource MyCare Ohio (Medicare-Medicaid Plan) 2 H6396_OH-SNP-P -5691550_C | Policy Updates Network Notification | June 2026AT CARESOURCE, WE LISTEN TO OUR PROVIDERS, AND WE STREAMLINE OUR BUSINESS PRACTICES TO MAKE IT EASIER FOR YOU TO WORK WITH US. We have worked to create a predictable cycle for releasing administrative, pharmacy, and reimbursement policies, so you know wha t to expect.Check back each month for a consolidated network notification of policy updates from CareSource.HOW TO USE THIS NETWORK NOTIFICATION Reference the list of policy updates. Note the effective date and impacted plans for each policy. Click the hyperlinked policy title to open the webpage containing the policy location. FIND OUR POLICIES ONLINETo access all CareSource policies, visit CareSource.com Providers Tools & Resources Provider Policies . Select your plan and state, then Pharmacy, Reimbursement, or Administrative. Each policy page has an archive where you can find previous versions of poli cies. PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACT Kisunla (donanemab-azbt intravenous infusion Lilly)JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Leqembi ( lecanemab-irmb intravenous infusion Eisai/Biogen)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Bildyos (denosumab-nxxp subcutaneousinjection Organon)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Bosaya (denosumab-kyqq subcutaneousinjection Biocon)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Conexxence (denosumab-bnht subcutaneous injection Fresenius Kabi) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION3 H6396_OH-SNP-P -5691550_C | Policy Updates Network Notification | June 2026 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACT Enoby (denosumab-qbde subcutaneousinjection Hikma)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Jubbonti (denosumab-bbdz subcutaneousinjection Sandoz)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Ospomyv (denosumab-dssb subcutaneous injection Samsung Bioepis ) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Prolia (denosumab subcutaneous injection Amgen JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Stoboclo (denosumab-bmwo subcutaneous injection Celltrion) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION4 H6396_OH-SNP-P -5691550_C | Policy Updates Network Notification | June 2026 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACT Evenity (romosozumab- aqqg subcutaneous injection Amgen) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Ibandronate intravenous infusion generic JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Reclast (zoledronic acid intravenous infusion Novartis, generic)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Tzield (teplizumab-mzwv intravenous infusion Provention/Sanofi) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Actemra (tocilizumab intravenous infusion Genentech/Roche) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION5 H6396_OH-SNP-P -5691550_C | Policy Updates Network Notification | June 2026 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACT Avtozma (tocilizumab- anoh intravenous infusion Celltrion) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Tofidence (tocilizumab-bavi intravenous infusion Biogen) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Tyenne (tocilizumab-aazg intravenous infusion Fresenius Kabi)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Spevigo (spesolimab-sbzo intravenous infusion Boehringer Ingelheim) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Orencia (abatacept intravenous infusion Bristol-Myers Squibb) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION6 H6396_OH-SNP-P -5691550_C | Policy Updates Network Notification | June 2026 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACT Fasenra (benralizumab subcutaneous injection AstraZeneca) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Waskyra (etuvetidigene autotemcel intravenous infusion Fondazione Telethon ETS) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) NEW Supprelin LA (histrelin acetate subcutaneous implant Endo) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Zoladex (goserelin acetate subcutaneous implant TerSera Therapeutics) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Vpriv (velaglucerase intravenous infusion Takeda) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION7 H6396_OH-SNP-P -5691550_C | Policy Updates Network Notification | June 2026 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACT Elelyso ( taliglucerase intravenous infusion Pfizer) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Elaprase ( idursulfase intravenous infusion Takeda) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Kyprolis (carfilzomib intravenous infusion Amgen/Onyx) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Tecentriq (atezolizumab intravenous infusion Genentech/Roche) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs subcutaneous injection Genentech) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION8 H6396_OH-SNP-P -5691550_C | Policy Updates Network Notification | June 2026 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACT Opdivo (nivolumab intravenous infusion Bristol-Myers Squibb) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Rybrevant ( amivantamab-vmjw intravenous infusion Janssen) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Imjudo ( tremelimumab-actl intravenous infusion AstraZeneca)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Kebilidi (eladocagene exuparvovec-tneq suspension for intraputaminal infusion PTC Therapeutics) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Stelara (ustekinumab intravenous infusion Janssen Biotech) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION9 H6396_OH-SNP-P -5691550_C | Policy Updates Network Notification | June 2026 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACTImuldosa (ustekinumab-srlf intravenous infusion Accord) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Otulfi (ustekinumab-aauz intravenous infusion Formycon/Fresenius)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Pyzchiva (ustekinumab-ttwe intravenous infusion Sandoz/Samsung) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Selarsdi (ustekinumab-aekn intravenous infusion Alvotech/Teva)JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Starjemza (ustekinumab-hmny intravenous infusion BioThera ) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION10 H6396_OH-SNP-P -5691550_C | Policy Updates Network Notification | June 2026 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACTSteqeyma (ustekinumab-stba intravenous infusion Celltrion) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Wezlana (ustekinumab-auub intravenous infusion Amgen) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Yesintek (ustekinumab-kfce intravenous infusion Biocon) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Ustekinumab intravenous infusion (Janssen Biotech) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Ustekinumab-ttwe intravenous infusion ( Quallent ) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION11 H6396_OH-SNP-P -5691550_C | Policy Updates Network Notification | June 2026 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACTImcivree (setmelanotide subcutaneous injection Rhythm) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Empliciti ( elotuzumab intravenous infusion Bristol-Myers Squibb) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Imlygic ( talimogene laherparepvec intralesional injection Amgen/ BioVex ) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Adstiladrin (nadofaragene firadenovec-vncg intravesical suspension Ferring) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Anktiva (nogapendekin alfa inbakicept-pmln intravesical solution ImmunityBio) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION12 H6396_OH-SNP-P -5691550_C | Policy Updates Network Notification | June 2026 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACT Encelto ( revakinagene taroretcel-lwey intravitreal implant Neurotech) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Otarmeni ( lunsotogene parvec-cwha intracochlear infusion Regeneron) JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISION Vabysmo ( faricimab-svoa intravitreal injection Genentech)JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) REVISIONAvlayah ( tividenofusp alfa-eknm intravenous infusion Denali) JULY 1, 2026CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) NEW Oncology (Injectable-CD38-Directed Cytolytic Antibody) – Sarclisa UM Medical Policy JULY 1, 2026 CARESOURCE MYCARE OHIO (MEDICARE-MEDICAID PLAN) HAP CARESOURCE MI COORDINATED HEALTH (HMO D-SNP) CARESOURCE DUAL ADVANTAGE (HMO D-SNP) CARESOURCE DUAL ADVANTAGE PLUS (HMO D-SNP) NEW13 H6396_OH-SNP-P -5691550_C | Policy Updates Network Notification | June 2026
Administrative Policy Statement MARKETPLACE PLANS Policy Name Policy Number Date Effective Medical Benefit Medications PAD-0013-MPP 07/01/2026 Policy Type Medical ADMINISTRATIVE Pharmacy Reimbursement Administrative Policy Statement s prepared by CSMG Co. and its affiliates (including CareSource) are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CSMG Co. and its affiliates (including CareSource) do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. Table of Contents A. SUBJECT ………………………………………………………………………………………………………….. 2 B. BACKGROUND …………………………………………………………………………………………………. 2 C. DEFINITIONS ……………………………………………………………………………………………………. 2 D. POLICY …………………………………………………………………………………………………………….. 3 E. CONDITIONS OF COVERAGE ……………………………………………………………………………. 4 F. RELATED POLICIES/RULES ………………………………………………………………………………. 4 G. REVIEW/REVISION HISTORY …………………………………………………………………………….. 4 Medical Benefit Medications Marketplace Plans PAD-0013-MPP Effective date: 07/01/20262 A. SUBJECT CareSource uses Pharmacy Policy Statements to determine coverage for medications that are covered under the medical benefit, as determined by the CareSource Pharmacy and Therapeutics (P&T) Committee. Pharmacy Policy Statements contain criteria designed to ensure that CareSource members safely receive effective medication. Some medical benefit medications may not be addressed by a specific Pharmacy Policy Statement. In that case, the reviewing pharmacists will make a clinical determination based on the information outlined here. B. BACKGROUND The intent of CareSource Policy Statements is to encourage appropriate selection of drug therapy for members according to product labeling, clinical guidelines, and/or clinical studies as well as to encourage use of Marketplace preferred drugs. The CareSource Policy Statement is a guideline for determining health care coverage for our members with benefit plans covering prescription drugs. Pharmacy Policy Statements are written on selected prescription drugs requiring prior authorization or step therapy. The Pharmacy Policy Statement is used as a tool to be interpreted in conjunction with the members specific benefit plan. Note: The Introduction section is for your general knowledge and is not to be construed as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals and is intended for providers. A provider can be a pers on, such as a doctor, nurse, psychologist, or dentist. A provider can also be a place where medical care is given, like a hospital, clinic, or lab. This policy informs providers about when a product or service may be covered. C. DEFINITIONS Administrative Review/Approval/Denial: a decision for coverage or non-coverage of a drug which is made regarding the organization and delivery of the drugs according to a members benefits, policies & procedures, and/or legislature & regulation which do not require clinical expertise or subject knowledge. Clinical Judgement: decisions made within the scope and expertise of a pharmacist following the review of subjective and objective medical data for a member. A pharmacist can use Clinical Judgement for the benefit determination for an exceptions request for a Medical Benefit Drug. If the request is outside the scope of a pharmacists expertise, a benefit determination will be made in collaboration with a medical director. Drug: a medication or substance which induces a physiologic effect on the body of a member (i.e., medication, agent, drug therapy, treatment, product, biosimilar drug, etc.) . Medical Benefit Drug: a drug that is usually administered by a healthcare provider or in a supervised healthcare setting and is billed to CareSource through the medical benefit and is subject to the appropriate member cost share based on the Schedule of Benefits (SOB) and/or Summary of Benefits and Coverage (SBC) . Medical Benefit Medications Marketplace Plans PAD-0013-MPP Effective date: 07/01/20263 Non-Preferred Drug: a drug that has been determined by CareSource to be less clinically efficacious or cost-effective for an FDA-approved use than other available drugs by the CareSource P&T Committee. Preferred Drug: the drug of choice for CareSource for an FDA-approved use as indicated on a Pharmacy Policy Statement available on the CareSource website and based on clinical efficacy and cost as determined by the CareSource P&T Committee. Specialty Drug: a drug which treats highly complex diseases and/or requires special handling or distribution and is usually high cost. Many of these drugs require prior authorization and may be dispensed at limited locations. Please see CareSources Specialty Drug List on the CareSource website. D. POLICY I. Medical Benefit Drugs may require review and approval by a pharmacist and/or medical director before being approved for payment. This policy will not supersede drug-specific clinical criteria developed and approved by the CareSource P&T Committee. When CareSource approves coverage of a Medical Benefit Drug it will be considered Medically Necessary when ALL of the following criteria have been met: A. Prior Authorization requests should be submitted for each Medical Benefit Drug with chart notes and member-specific documentation AND B. The members indication, dose, and duration for the use of the requested Medical Benefit Drug is approved by the Food & Drug Administration (FDA) or an indication supported in the compendia or current peer-reviewed literature or evidence-based guidelines A ND C. One of the following is true: 1. The Medical Benefit Drug is a Preferred Drug by CareSource OR 2. The member is unable to take the Preferred Drug(s) because: a. The member has a clinical condition for which there is no Marketplace Preferred Drug and/or needed dosage form suitable to treat the members diagnosis OR b. The Marketplace Preferred Drug(s) is/are not recommended based on published guidelines or clinical literature OR c. The Marketplace Preferred Drug(s) is/are expected to be ineffective or less effective for the member based on submitted documentation and medical history OR d. The Marketplace Preferred Drug(s) is/are expected to cause an adverse effect based on submitted documentation and medical history. II. For all Medical Benefit Drugs, including those that have drug-specific clinical criteria: A. If requested agent is a Medical Benefit Drug with a self-administered dosage form available, documentation of the rationale that the member is unable to utilize the self-administered version must be included. Self-administered drugs are generally not covered under the medical benefit. B. Documentation that the drug being requested is planned to be administered in the appropriate site of care. Medical Benefit Medications Marketplace Plans PAD-00 13-MPP Effective date: 07/01/20264 III. For Reauthorization: A. Documentation has been provided showing the member has had a positive response to therapy; AND B. Documentation has been provided showing the member is compliant with therapy; AND C. The requested use and dosage remain consistent with FDA-approved prescribing information in the drug package insert. E. CONDITIONS OF COVERAGE HCPCS CPT A UTHORIZATION PERIOD : as determined by the approving pharmacists Clinical Judgement F. RELATED POLICIES/RULES Non-Formulary Medications Policy Off Label Medication Requests Policy Drug-specific policies posted on the CareSource website may apply G. REVIEW/REVISION HISTORY DATE S ACTIONDate Issued 11/07/2019 Drafted policy language; updated references to SOB and SBCDate Revised 11/17/2021 Annual review, no changes. 12/19/2022 Annual review, no changes.6/6/2023 Removed Medical Necessity and updated related policies and rules to align with new policy titles.5/21/24 Annual review, no changes5/22/2025 Added reauthorization criteria2/17/2026 Annual review, no changes.4/7/2026 Added criteria regarding self-administered drugs and site of care. Date Effective 10/01/2025 Date Archived H. REFERENCES1. Definitions for Administrative Review or Clinical Judgement: Ombudsman Saskatchewan, Canada; Administrative versus Clinical Decisions January 2016. 2. 45 CFR Chapter A Subchapter B-156.122 Prescription drug benefits. 3. 2026 NCQA Standards and Guidelines for the Accreditation of Health Plans.
Notice Date: June 10 , 2026 To: CareSource MyCare Ohio (HMO D-SNP) (Ohio Next Generation MyCare) FIDE Providers From: CareSource Subject: June 2026 Policy Updates Revision Effective Date: July 1, 2026 and August 1, 2026 This notification is a revision to the June 2026 Policy Updates Network Notification. An updated version of the Community Behavioral Health Services Utilization Management PY-1816 has been added. Summary At CareSource, we listen to our providers, and we streamline our business practices to make it easier for you to work with us. We have worked to create a predictable cycle for releasing administrative, medical, and reimbursement policies, so you know what to expect. Check back each month for a consolidated network notification of policy updates from CareSource. How to Use This Network Notification Reference the list of policy updates. Note the effective date and impacted plans for each policy. Click the hyperlinked policy title to open the webpage with the full policy. Find Our Policies Online To access all CareSource policies, visit CareSource.com > Providers > Tools & Resources > Provider Policies. Select your plan and state, then the type of policy. Each revised policy has a previous version that can be referenced on the corresponding archived policy webpage. Policies Policy Name & Number Policy Type Plan Effective Date New or Revised?Medical Record Documentation Standards for Practitioners AD-1598 ADMINISTRATIVE Ohio MyCare FIDE AUGUST 1, 2026 REVISION Modifiers PY-1692 REIMBURSEMENT Ohio MyCare FIDE AUGUST 1, 2026 REVISION Provider Home Visits AD-1589 ADMINISTRATIVE Ohio MyCare FIDE AUGUST 1, 2026 REVISION Community Behavioral Health Services Utilization Management PY-1816 REIMBURSEMENT OHIO MyCare FIDE JULY1, 2026 NEWH6396_OH-SNP-P-5624900a _C
CareSource promotes access to care by partnering with health care providers to ensure our members receive the best possible health care services. It includes evaluation of the availability, accessibility, and acceptability of services rendered to patients by participating providers. CareSource expects network providers to have procedures in place to see patients within the following time frames, and to offer office hours to their CareSource patients that are no less (in number or scope) than those offered to non-CareSource patients. In addition, a members waiting time at a providers office should be no more than one hour from the scheduled appointment time, except when the provider is unavailable due to an emergency. Ensuring coverage that allows your patients to speak with a practitioner is important for them to receive appropriate care and maintain their health.Please keep in mind the following access standards for each level of care: PRIMARY CARE PROVIDERS (PCPs)Service Type Maximum Appointment Wait Time from the Day of Request 1 UrbanRural Frontier Routine Care Visit (Adult and Pediatric)* 10 business days15 business days15 business daysUrgent Care Within 48 hoursEmergency Needs Immediately upon presentation*These appointment wait time standards do not apply to regularly scheduled visits that are for monitoring a chronic medical condition if their schedule calls for visits that are less frequent than would be allowed by the standards. NON-PCP (SPECIALISTS) PROVIDERSService Type Maximum Appointment Wait Time from the Day of Request 1 UrbanRural Frontier PHYSICAL/OCCUPATIONAL/SPEECH THERAPY15 business days20 business days20 business daysOBSTETRICS AND GYNECOLOGY (OB/GYN)OB/GYN (Other than Prenatal Care) 10 business days15 business days15 business daysFirst and Second Trimester Visit 7 calendar days10 calendar days 10 calendar daysThird Trimester or High-Risk Care Visit 3 calendar days5 calendar days5 calendar daysUrgent Care Within 48 hoursEmergency Needs Immediately upon presentation ACCESS TO CARE AND AFTER HOURS STANDARDS BEHAVIORAL HEALTH (BH) AND SUBSTANCE USE DISORDER (SUD) PROVIDERSService TypeMaximum Appointment Wait Time from the Day of Request 1 UrbanRural Frontier Initial Visit for Routine Care 10 business daysFollow-up Routine Care 30 calendar daysOutpatient Mental Health and SUD Treatment (Adult and Pediatric) 10 business daysUrgent Care Within 48 hoursEmergency Needs Immediately upon presentationNon-Life Threatening Emergency Care Within 6 hours 1Providers should see members as expeditiously as the members condition and severity of symptoms warrant. It is expected that if a provider is unable to see the member within the designated time frame, CareSource will facilitate an appointment with another participating provider, or a non-participating provider, when necessary.Update to After-Hours Standard Effective July 1, 2026: PCP and BH providers must provide 24-hour availability to their CareSource patients by telephone. Whether through an answering machine or a taped message used after hours, patients should be given the means to contact their PCP/BH* provider or a back-up provider to be triaged for care. It is not acceptable to use a phone message that does not provide access to you or your back-up provider and only recommends emergency department use for after hours. *BH providers may refer their patients to the 988 Suicide & Crisis Hotline or the CareSource Crisis Line at 1-833-687-7396 (TTY: 711 or 1-800-326-6868) if a provider is not available for the call.For the best interest of our members and to promote their positive health care outcomes, CareSource supports and encourages continuity of care and coordination of care between medical care providers, as well as between physical and behavioral health providers.Talking to PatientsCareSource regularly provides education to our members about appropriate use of services. Partnering with you gives us the opportunity to educate members about how to access the right care to meet their needs and remind them to: Contact their PCP/BH provider first for non-emergency situations.Visit an urgent care to be seen quickly when a PCP cannot be reached.Consider visiting retail health clinics or convenience care clinics that are open late and on weekends.Visit a PCP for routine care, not the emergency department.Nurse Advice LineCareSource helps members decide where to go for care when they are unsure. Your patients can call our 24-Hour Nurse Advice Line at 1-833-687-7365 (TTY: 711 or 1-800-326-6868) and a nurse will help them make the decision. Members can call 24 hours a day, seven days a week at no cost.NV-MED-P-4317900a | 2026 CareSource. All Rights Reserved.Thank you for partnering with CareSource! Questions? Please contact Provider Services at 1-833-230-2112, Monday through Friday 8 a.m. to 6 p.m., Pacific Time (PT).
Notice Date: June 1, 2026 To: CareSource Ohio Medicaid Providers From: CareSource Subject: June 2026 Policy Updates Effective Date: July 1, 2026 and August 1, 2026 Summary At CareSource, we listen to our providers, and we streamline our business practices to make it easier for you to work with us. We have worked to create a predictable cycle for releasing administrative, medical, and reimbursement policies, so you know what to expect. Check back each month for a consolidated network notification of policy updates from CareSource. How to Use This Network Notification Reference the list of policy updates. Note the effective date and impacted plans for each policy. Click the hyperlinked policy title to open the webpage with the full policy. Find Our Policies Online To access all CareSource policies, visit CareSource.com > Providers > Tools & Resources > Provider Policies. Select your plan and state, then the type of policy. Each revised policy has a previous version that can be referenced on the corresponding archived policy webpage. Policies Policy Name & Number Policy Type Plan Effective DateNew or Revised PolicyDiagnostic Colonoscopy and/or Sigmoidoscopy PY-1592 REIMBURSEMENT OHIO MEDICAID AUGUST 1, 2026 REVISION Durable Medical Equipment (DME) Modifiers PY-0022 REIMBURSEMENT OHIO MEDICAID AUGUST 1, 2026 REVISION Itemized Billing AD-0857 ADMINISTRATIVE OHIO MEDICAID AUGUST 1, 2026 REVISION Medical Record Documentation Standards for Practitioners AD-0753 ADMINISTRATIVE OHIO MEDICAID AUGUST 1, 2026 REVISION Modifiers PY-1345 REIMBURSEMENT OHIO MEDICAID AUGUST 1, 2026 REVISION Unlisted and Miscellaneous Codes PY-1456 REIMBURSEMENT OHIO MEDICAID AUGUST 1, 2026 REVISION Private Duty Nursing MM-1510 MEDICAL OHIO MEDICAID AUGUST 1, 2026 REVISION Provider Home Visits AD-1165 ADMINISTRATIVE OHIO MEDICAID AUGUST 1, 2026 REVISION Community Behavioral Health Services Utilization Management PY-1748 REIMBURSEMENT OHIO MEDICAID July 1, 2026 NEW OH-MED-P- 5618004
Notice Date: June 10 , 2026To: Ohio Medicaid and CareSource MyCare Ohio Providers From: CareSource Subject : OAC Rule 5160-1-17.9 Ordering, Referring and Prescribing Providers Effective Date: January 1, 202 7 SummaryThe Ordering, Referring, or Prescribing (ORP) provider’s National Provider Identifier (NPI) number must be submitted on claims that are submitted by or for the ordering, referring, or prescribing providers.Claims submitted without the ORP provider’s NPI number are subject to rejection or denial. This requirement ensures compliance with 42 CFR 455.440 and Ohio Administrative Code (OAC) Rule 5160-1-17.9. ImpactThis rule applies to all Ohio Medicaid enrolled providers delivering services through managed care entities (MCEs) and the fee-for-service program. Claims and encounters for certain services must include the ORP providers NPI to be processed. Key Provider Education Components:Provider Types Eligible as ORP-Only (Reporting-Only) Providers:The following practitioners can enroll as reporting-only or ORP-only providers and must be identified on claims as the attending, ordering, or referring provider within their scope of practice: Physicians (20) Physician Assistants (24) Chiropractors (27) Dentists (30) Optometrists (35) Podiatrists (36) Licensed Psychologists (42) Advanced Practice Registered Nurses: o Clinical Nurse Specialists (65) o Certified Nurse Midwives (71) o Certified Nurse Practitioners (72) Services Requiring ORP NPI Reporting: Skilled therapies (physical, occupational, speech therapy, audiology) require ordering provider NPI for Federally Qualified Health Centers (provider type 12), Rural Health Centers (05), and Clinics (50). Durable Medical Equipment (DME), imaging, radiology, and laboratory services require ordering provider NPI. Consultation codes (99242-99255) require referring provider NPI when rendered by Physician, PA, or APRN. Dental services such as CT scans, anesthesia, dentures, and comprehensive dental treatment require ordering provider NPI. Transportation services including ground ambulance and wheelchair van transports require ordering provider NPI. Behavioral health agencies (provider types 84, 95) require ordering provider NPI for laboratory services and select nursing services (withdrawal management, medication administration, evaluation and management 99211 by RN/LPN). Home health (nursing, skilled therapy, aide, private duty), hospice, and various nursing facility services require ordering or attending provider NPI as applicable. Institutional Claims Attending Practitioner NPI Requirement: Hospitals (01), Psychiatric Hospitals (02), PRTF (03), Nursing Facilities (86), State Operated ICF (88), Non-State Operated ICF (89).Professional Claims Ordering Practitioner NPI Requirement: Durable Medical Equipment Suppliers (76), Independent Diagnostic Testing Facilities (79), Independent Laboratories (80).Compliance & Enforcement Starting January 1, 2027, claims missing required ORP provider NPIs will be denied by CareSource . Providers must ensure ORP NPIs are valid and enrolled in the Provider Network Management system. Providers not yet enrolled as required ORP providers should be directed to enroll via the Provider Network Management (PNM) module. Questions?For questions related to this communication, please contact: Medicaid: 1-800-488-0134 , available Monday through Friday, 7 a.m. to 8 p.m. Eastern Time (ET ) CareSource MyCare Ohio: 1-800-488-0134 , available Monday through Friday, 8 a.m. to 6 p.m. ET OH-Multi-P-5564870
02/1 1/202 6 Express Scripts Strategic Development, Inc ., 202 6. All Rights Reserved. This document is confidential and proprietary to Express Scripts Strategic Development. Unauthorized use and distribution are prohibited. U TILIZATION M ANAGEMENT M EDICAL POLICY POLICY : Gonadotropin-Releasing Hormone Agonists Implants Utilization Management Medical Policy Supprelin LA (histrelin acetate subcutaneous implant Endo) Zoladex (goserelin acetate subcutaneous implant TerSera Therapeutics)REVIEW DATE : 02/ 11/2026 ; selected revision 04/01/2026 OVERVIEW Supprelin LA and Zoladex are gonadotropin-releasing hormone (GnRH) agonists implants. 1-3 Supprelin LA is indicated for the treatment of central precocious puberty in children. 1 Zoladex is indicated for the following conditions: 2, 3 Breast cancer, palliative treatment of advanced breast cancer in pre-and perimenopausal women (Zoladex 3.6 mg implant only). Endometrial-thinning , use as an endometrial-thinning agent prior to endometrial ablation for dysfunctional uterine bleeding (Zoladex 3.6 mg implant only). Endometriosis, including pain relief and reduction of endometriotic lesions for the duration of therapy (Zoladex 3.6 mg implant only). Labeling notes that experience with Zoladex for this indication has been limited to women 18 years of age. 2 Prostate cancer, in combination with flutamide for the management of locally confined Stage T2b-T4 (Stage B2-C). Prostate cancer, advanced carcinoma or palliative treatment. Zoladex 3.6 mg (equivalent to 3.8 mg goserelin acetate) is approved for all the diagnoses above . Zoladex 10.8 mg (equivalent to 11.3 mg goserelin acetate) is only indicated for prostate cancer. Guidelines Central precocious puberty , also known as gonadotropin-dependent precocious puberty, is caused by early maturation of the hypothalamic-pituitary-gonadal axis. 5 The standard of care for central precocious puberty is GnRH agonists. The European Society for Paediatric Endocrinology and the Lawson Wilkins Pediatric Endocrine Society convened a consensus conference (2009) to review the use of GnRH agonists in pedia tric patients with central precocious puberty. 6 The panel noted that the available GnRH agonists (including leuprolide, tr iptorelin, and histrelin implants) are effective despite different routes of administration, dosing, and duration of action. An update by the International Consortium (2019) reiterates the use of GnRH agonists (e.g., leuprolide, triptorelin, and histrelin implants) for the treatment of central precocious puberty. 7 GnRH agonists are generally well-tolerated in children and adolescents. Gender-dysphoric/gender-incongruent persosns: According to the Endocrine Society Guidelines for the treatment of gender dysphoric/gender-incongruent persons and the World Professional Association for Transgender Health, GnRH agonists can be used off-label for the treatment of gender-dysphoric/gender-incongruent persons to suppress physical changes of puberty and gonadal function. 17,18 Pubertal hormonal suppression should typically be initiated after the adolescent first exhibits physical changes of pubert y (Tanner stages G2/B2). An advantage to using a GnRH analog is that the effects can be reversed; pubertal suppression can be discontinued if the individual no longer wishes to transition. Upon discontinuation of Gonadotropin-Releasing Hormone Agonists Implants UM Medical Policy Page 2 02/1 1/202 6 Express Scripts Strategic Development, Inc ., 202 6. All Rights Reserved. This document is confidential and proprietary to Express Scripts Strategic Development. Unauthorized use and distribution are prohibited. therapy, spontaneous pubertal development has been shown to resume. GnRH analogs can also be used in patients during late puberty to suppress the hypothalamic-pituitary-gonadal axis to allow for lower doses of cross-sex hormones. 19 In addition to use in adolescents, GnRH analog therapy is also used in adults, particularly male-to-female patients. 13 In addition to the approved indications, GnRH agonists have been used for other conditions. The National Comprehensive Cancer Network (NCCN) guidelines address the use of GnRH agonists in a number of guidelines: Adolescent and young adult oncology NCCN guidelines (version 2.2026 February 27, 2026 ) note GnRH agonists may be used in (oncology) protocols that are predicted to cause prolonged thrombocytopenia and present a risk for menorrhagia.20 There are some limited data on GnRH agonists to preserve ovarian function during chemotherapy and some have shown that GnRH agonists may be beneficial for fertility preservation, although the guidelines note further investigation is needed and other fert ility preservation modalities should still be pursued. Breast cancer: The NCCN breast cancer guidelines (version 1.202 6 January 16, 2026) note methods for ovarian function suppression in breast cancer includes goserelin 3.6 mg subcutaneous every 4 weeks or 10.8 mg subcutaneous every 12 weeks.4 Other previous information from NCCN regarding goserelin in breast cancer is under discussion. Head and neck cancer salivary gland tumors: The NCCN head and neck cancer guidelines (version 1.2026 December 8, 2025 ) notes that goserelin (category 2B) is useful for androgen receptor positive salivary gland tumors which are recurrent, unresectable, or metastatic. 9 ,1 1 Goser elin can also be used (category 2A) with abiraterone and prednisone. Dosing used in NCCN references was 3.6 mg subcutaneously once every 28 days. 14-16 Ovarian cancer, including fallopian tube cancer and primary peritoneal cancer: The NCCN ovarian cancer guidelines (version 3.2025 July 16, 2025) notes goserelin as other hormone therapy options for endometrioid carcinoma, low-grade serous carcinoma, malignant sex cord stromal tumors (for granulosa cell tumors) , and recurrence therapy for platinum-sensitive disease. 9 ,1 2 Goserelin is an option for hormonal therapy. Prostate cancer: The NCCN prostate cancer guidelines (version 5.2026 January 23, 2026) list goserelin , leuprolide, and triptorelin as androgen deprivation therapy options for use in various settings: clinically localized disease, regional disease, positive lymph nodes and/or adverse features post-radical prostatectomy, first persistence/recurrence, castration-sensitive disease, metastatic castration-sensitive disease, and castration-resistant disease. 8 Uterine cancer: The NCCN uterine neoplasm guidelines (version 2.2026 November 14, 2025 ) notes that prescribers may consider GnRH analogs with aromatase inhibitors in patients who are premenopausal and not suitable for surgery for low-grade endometrial stromal sarcoma, adenosarcoma without sarcomatous overgrowth, or hormone receptor-positive uterine sarcomas. 9 ,1 0 POLICY STATEMENT Prior Authorization is recommended for medical benefit coverage of Supprelin LA and Zoladex . Approval is recommended for those who meet the Criteria and Dosing for the listed indications. Extended approvals are allowed if the patient continues to meet the Criteria and Dosing. Requests for doses outside of the established dosing documented in this policy will be considere d on a case-by-case basis by a clinician (i.e., Medical Director or Pharmacist). All approvals are provided for the duration noted below. In cases where the approval is authorized in months, 1 month is equal to 30 days. Because of the specialized skills required for evaluation and diagnosis of patients treated with Zolade x as well as the monitoring required for adverse events and long-term efficacy, approval requires these agents to be prescribed by or in consultation with a physician who specializes in the condition being treated. Gonadotropin-Releasing Hormone Agonists Implants UM Medical Policy Page 3 02/1 1/202 6 Express Scripts Strategic Development, Inc ., 202 6. All Rights Reserved. This document is confidential and proprietary to Express Scripts Strategic Development. Unauthorized use and distribution are prohibited. Automation: None. Indications and/or approval conditions noted with [eviCore] are managed by eviCore healthcare for those clients who use eviCore for oncology and/or oncology-related reviews. For these conditions, a prior authorization review should be directed to eviCore at www.eviCore.com. RECOMMENDED AUTHORIZATION CRITERIAI . Coverage of Supprelin LA i s recommended in patients who meet the following criteria: FDA-Approved Indication 1. Central Precocious Puberty. Approve for 1 year. Dosing. Approve one implant (50 mg) once every 12 months ( inserted subcutaneously in the upper arm ). Other Uses with Supportive Evidence 2. Gender Dysphoric/Gender-Incongruent Persons; Persons Undergoing Gender Reassignment (Female-To-Male [FTM] or Male-to-Female [MTF]). Approve for 1 year if prescribed by or in consultation with an endocrinologist or a physician who specializes in the treatment of transgender patients. Dosing . Approve one implant (50 mg) once every 12 months (inserted subcutaneously in the upper arm). II. Coverage of Zoladex is recommended in patients who meet one of the following criteria: FDA-Approved Indications 1. Abnormal Uterine Bleeding. Approve for 2 months if the patient meets BOTH of the following (Aand B): A) Zoladex is used as an endometrial-thinning agent prior to endometrial ablation; AND B) The medication is prescribed by or in consultation with an obstetrician-gynecologist or a health care practitioner who specializes in the treatment of womens health. Dosing. Approve Zoladex 3.6 mg implant once every 28 days (inserted subcutaneously into the anterior abdominal wall). 2. Breast Cancer. [eviCore]. Approve for 1 year if the medication is prescribed by or in consultation with an oncologist. Dosing. Approve ONE of the following dosage regimens (inserted subcutaneously into the anterior a bdominal wall ) [A or B]: A) Zoladex 3.6 mg implant once every 28 days; OR Gonadotropin-Releasing Hormone Agonists Implants UM Medical Policy Page 4 02/1 1/202 6 Express Scripts Strategic Development, Inc ., 202 6. All Rights Reserved. This document is confidential and proprietary to Express Scripts Strategic Development. Unauthorized use and distribution are prohibited. B) Zoladex 10.8 mg implant once every 12 weeks. 3. Endometriosis. Approve for 6 months if the patient meets BOTH of the following (A and B): A) Patien t is 18 years of age; AND B) The medication is prescribed by or in consultation with an obstetric ian-gynecologist or a health care practitioner who specializes in the treatment of womens health. Dosing. Approve Zoladex 3.6 mg implant once every 28 days (inserted subcutaneously into the anterior abdominal wall) . 4. Prostate Cancer. [eviCore]. Approve for 1 year if the medication is prescribed by or in consultation with an oncologist. Dosing. Approve ONE of the following dosage regimens (inserted subcutaneously into the anterior abdominal wall) [A or B]: A) Zoladex 3.6 mg implant once every 28 days; OR B) Zoladex 10.8 mg implant once every 12 weeks. Other Uses with Supportive Evidence 5. Gender Dysphoric/Gender-Incongruent Persons; Persons Undergoing Gender Reassignment (Female-To-Male [FTM] or Male-to-Female [MTF]). Approve for 1 year if prescribed by or in consultation with an endocrinologist or a physician who specializes in the treatment of transgender patients. Dosing . Approve ONE of the following dosage regimens (inserted subcutaneously into the anterior abdominal wall) [A or B]: A) Zoladex 3.6 mg implant once every 28 days; OR B) Zoladex 10.8 mg implant once every 12 weeks. 6. Head and Neck Cancer Salivary Gland Tumors . [eviCore]. Approve for 1 year if the patient meets ALL of the following (A, B, and C): A) Patient has recurrent, unresectable, or metastatic disease; AND B) Patient has androgen receptor-positive disease; AND C) The medication is prescribed by or in consultation with an oncologist. Dosing. Approve Zoladex 3.6 mg implant once every 28 days (inserted subcutaneously into the anterior abdominal wall). 7. Ovarian Cancer, including Fallopian Tube Cancer and Primary Peritoneal Cancer . [eviCore]. Approve for 1 year if the medication is prescribed by or in consultation with an oncologist. Dosing. Approve Zoladex 3.6 mg implant once every 28 days (inserted subcutaneously into the anterior abdominal wall). Gonadotropin-Releasing Hormone Agonists Implants UM Medical Policy Page 5 02/1 1/202 6 Express Scripts Strategic Development, Inc ., 202 6. All Rights Reserved. This document is confidential and proprietary to Express Scripts Strategic Development. Unauthorized use and distribution are prohibited. 8. Preservation of Ovarian Function/Fertility in Patients Undergoing Chemotherapy . [eviCore].Approve for 1 year if the medication is prescribed by or in consultation with an obstetrician-gynecologist or an oncologist. Dosing . Approve ONE of the following dosage regimens (inserted subcutaneously into the anterior abdominal wall) [A or B]: A) Zoladex 3.6 mg implant once every 28 days; OR B) Zoladex 10.8 mg implant once every 12 weeks. 9. Prophylaxis or Treatment of Uterine Bleeding or Menstrual Suppression in Patients with Hematologic Malignancy, or Undergoing Cancer Treatment, or Prior to Bone Marrow/Stem Cell Transplantation . [eviCore]. Approve for 1 year if the medication is prescribed by or in consultation with an oncologist. Dosing . Approve ONE of the following dosage regimens (inserted subcutaneously into the anterior abdominal wall) [A or B]: A) Zoladex 3.6 mg implant once every 28 days; OR B) Zoladex 10.8 mg implant once every 12 weeks. 10. Uterine Cancer. [eviCore]. Approve for 1 year if the medication is prescribed by or in consultation with an oncologist. Dosing. Approve Zoladex 3.6 mg implant once every 28 days (inserted subcutaneously into the anterior abdominal wall). CONDITIONS NOT RECOMMENDED FOR APPROVAL Coverage of Supprelin LA and Zoladex is not recommended in the following situations: 1. Peripheral Precocious Puberty (also known as GnRH-independent precocious pu berty). Children with peripheral precocious puberty do not respond to GnRH agonist therapy. 7 Treatment is directed at removing or blocking the production and/or response to the excess sex steroids, depending on the cause (e.g., surgically removing human chorionic gonadotropin-secreting tumors or using glucocorticoids to treat defects in adrenal steroidogenesis [such as classic congenital adrenal hyperplasia]). 2. Coverage is not recommended for circumstances not listed in the Recommended Authorization Criteria . Criteria will be updated as new published data are available. REFERENCES 1. Supprelin LA [prescribing information]. Malvern, PA : Endo ; September 20 25. 2. Zoladex 3.6 mg implant [prescribing information]. Deerfield, IL: TerSera Therapeutics; September 20 25. 3. Zoladex 10.8 mg implant [prescribing information]. Deerfield , IL: TerSera Therapeutics; September 20 25. 4. The NCCN Breast Cancer Clinical Practice Guidelines in Oncology ( version 1.202 6 January 16, 202 6). 20 26 National Comprehensive Cancer Network. Available at: http://www.nccn.org. Accessed on February 8 , 2026 . 5. Eugster EA. Treatment of central precocious puberty. JEndo Soc . 2019;3:965-972. Gonadotropin-Releasing Hormone Agonists Implants UM Medical Policy Page 6 02/11/2026 Express Scripts Strategic Development, Inc ., 202 6. All Rights Reserved. This document is confidential and proprietary to Express Scripts Strategic Development. Unauthorized use and distribution are prohibited. 6. Carel JC , Eugster EA , Rogol A , et al. Consensus statement on the use of gonadotropin-releasing hormone analogs in children. Pediatrics . 2009 Apr;123(4):e752-62. 7. Krishna KB, Fuqua JS, Rogol AD, et al. Use of gonadotropin-releasing hormone analogs in children: update by an international consortium. Horm Res Paediatr. 2019;91:357-372. 8. The NCCN Prostate Cancer Clinical Practice Guidelines in Oncology ( version 5.202 6 January 23 , 202 6). 20 26 National Comprehensive Cancer Network. Available at: http://www.nccn.org. Accessed on February 8, 2026. 9. The NCCN Drugs and Biologics Compendium. 2026 National Comprehensive Cancer Network. Available at: http://www.nccn.org. Accessed on February 8, 202 6. Search term: goserelin acetate. 10. The NCCN Uterine Neoplasms Clinical Practice Guidelines in Oncology (version 2 .2026 November 14, 202 5). 2025 National Comprehensive Cancer Network. Available at: http://www.nccn.org. Accessed on February 8, 202 6. 11. The NCCN Head and Neck Cancers Clinical Practice Guidelines in Oncology (version 1 .2026 December 8, 202 5). 2025 National Comprehensive Cancer Network. Available at: http://www.nccn.org. Accessed on February 8, 202 6. 12. The NCCN Ovarian Cancer Clinical Practice Guidelines in Oncology (version 3.2025 July 16, 202 5). 2025 National Comprehensive Cancer Network. Available at: http://www.nccn.org. Accessed on February 8, 2026. 13. Spack NP. Management of transgenderism. JAMA. 2013;309:478-484. 14. Honma Y, Monden N, Yamazaki K, et al. Yatagarasu: A single-arm, open-label, phase 2 study of apalutamide plus goserelin for patients with far locally advanced or recurrent/metastatic and androgen receptor-expressing salivary gland carcinoma [abstract]. JClin Oncol. 2022;40 (Suppl): Abstract 6079. 15. Patel M, Fojioka N, Pease DF, et al. BTCRC-HN17-111, A phase 2 trial of ADT (Goserelin) in combination with pembrolizumab for patients with advanced salivary gland tumors expressing androgen receptor [abstract]. JClin Oncol. 2022;40 (Suppl): Abstract e18091. 16. Boon E, van Boxtel W, Buter J, et al. Androgen deprivation therapy for androgen receptor-positive advanced salivary duct carcinoma: A nationwide case series of 35 patients in the Netherlands. Head Neck. 2018;40:605-613. 17. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guidelines. JClin Endocrinol Metab . 2017;102:3869-3903. 18. World Professional Association for Transgender Health (WPATH). Standards of Care for the health of transgender and gender diverse people (version 8). Available at: Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 (tandfonline.com) . Accessed on January 9, 2026. 19. Rosenthal SM. Approach to the patient: transgender youth: endocrine considerations. JClin Endocrine Metab. 2014;99:4379-4389. 20. The NCCN Adolescent and Young Adult Oncology Clinical Practice Guidelines in Oncology (version 2.2026 February 27, 2026). 2026 National Comprehensive Cancer Network. Available at: http://www.nccn.org. Accessed on March 27, 2026. HISTORY Type of Revision Summary of Changes Review Date Annual Revision No criteria changes. 02/15/2023 Annual Revision Head and Neck Cancer Salivary Gland Tumors ; Ovarian Cancer, including Fallopian Tube Cancer and Primary Peritoneal Cancer; Uterine Cancer. These new conditions and criteria w ere added to the policy. Breast Cancer: Removal of criteria related to premenop ausal or perimenopausal women. Added the following dosing regimen for approval: Zoladex 10.8 mg every 12 weeks. 02/21 /2024 Annual Revision Removed Vant as from the policy (obsolete). 02/1 2/2025 Annual Revision Other Uses with Supportive Evidence: Gender-Dysphoric/Gender-Incongruent Persons; Persons Undergoing Gender Reassignment (Female-To-Male or Male-To-Female) was added as a new condition of approval for Supprelin LA and Zoladex . 02/11/2026 Selected Revision Preservation of Ovarian Function/Fertility in Patients Undergoing Chemotherapy; Prophylaxis or Treatment of Uterine Bleeding or Menstrual Suppression in Patients with Hematologic Malignancy, or Undergoing Cancer Treatment, or Prior to Bone Marrow/Stem Cell Transplantation : These conditions of approval were added to the policy for Zoladex. 04/01/2026
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