CareSourcePASSE.comRe: Summary of Formulary/Prior Authorization Changes Effective JANUARY 1, 2026 Your health care is our priority. That is why we are writing to tell you that on JANUARY 1, 2026 , there will be changes made to Arkansas Medicaids Preferred Drug List (PDL) and CareSource PASSEs management of products not on Arkansas Medicaids PDL. A PDL is a list of preferred drugs . SUMMARY OF CHANGES TO THE ARKANSAS MEDICAID PDL EFFECTIVE JANUARY 1, 2026: THE FOLLOWING MEDICATION( S) WILL BE PREFERRED ON THE PDL EFFECTIVE JANUARY 1, 2026Product Name Dose(s) NotesAcetylcysteine (Generic for Acetadote ) vial 6 g/30 mL Updated to preferred, effective 10/29/25 Cardizem tablet 30 mg Updated to preferred, effective 10/1/25 Diltiazem 24h ER CD (Generic for Cardizem CD ) capsule 120 mg Doxycycline hyclate (Generic for Acticlate ) tablet 75 mg, 150 mg Doxycycline monohydrate (Generic for Adoxa ) tabletAll Epoprostenol (Generic for Veletri ) vial All Mesalamine ER (Generic for Apriso ) capsule All Updated to preferred, effective 10/1/25 Pyzchiva (Biosimilar to Stelara ) syringe, vial 45 mg, 90 mg Applicable to 45mg syringe, vial & 90mg syringe. Preferred with criteria. Brand Stelara is already non-preferred Steqeyma (Biosimilar to Stelara ) syringe All Preferred with criteria. Brand Stelara is already non-preferred Ticagrelor (Generic for Brilinta ) tablet All Ziac tablet 10-6.25 mg THE FOLLOWING MEDICATION(S) WILL BE NON-PREFERRED ON THE PDL EFFECTIVE JANUARY 1, 2026Product Name Dose(s) NotesBrilinta tablet All Centany ointment 2% CareSourcePASSE.com Product Name Dose(s) Notes Doxycycline monohydrate (Generic for Vibramycin ) suspension 25 mg/5 mL GoLYTELY solution N/A Morgidox capsule 50mg Testosterone enanthate (Generic for Delatestryl ) vial 200 mg/ml Tetracycline (Generic for Sumycin ) capsule All Veletri vial All THE FOLLOWING MEDICATION(S) HAVE A CHANGE IN PRIOR AUTHORIZATION/ CRITERIA ON THE PDL EFFECTIVE JANUARY 1, 2026Product Name Dose(s) NotesAdalimumab-ryvk (CF) (Generic for Simlandi Biosimlar to Humira ) autoinjector 80 mg Updated age and quantity limits effective 9/5/25 Alosetron (Generic for Lotronex ) tablet All Updated age limit effective 10/1/25 Amitiza capsule All Updated age limit effective 10/1/25 Arbli suspension 10 mg/mL Updated age limit effective 10/1/25 Azelaic acid (Generic for Finacea ) gel 15% Updated age limit effective 10/1/25 Bildyos syringe 60 mg/ml Updated quantity limit effective 9/11/25 and age limit effective 9/29/25 Bilprevda vial 120 mg/ 1.7 mL Updated age and quantity limits effective 9/11/25 Blujepa tablet 750 mg Updated age and quantity limits effective 9/8/25 Bosentan (Generic for Tracleer ) tablet All Updated age limit effective 8/20/25 Brekiya autoinjector 1 mg/mL Updated quantity limit effective 9/2/25 Brimonidine (Generic for Mirvaso ) gel pump 0.33% Updated age limit effective 10/1/25Cresemba capsule All Updated age limit effective 9/30/25Dalbavancin and Brand Dalvance vial All Updated quantity limit effective 11/3/25 Dawnzera injection All Updated age and quantity limits effective 8/21/25 Deflazacort (Generic for Emflaza ) tablet All Updated age limit effective 10/31/25 Dexcom 15-day sensor N/A Updated quantity limit effective 9/1/25 Doptelet sprinkle capsule 10 mg Updated age limit effective 9/22/25 and quantity limit effective 9/29/25 CareSourcePASSE.com Product Name Dose(s) Notes Eliquis sprinkle capsule, tablet for suspension Multiple Updated quantity limit for sprinkle capsule effective 9/10/25 and quantity limit for tablet for suspension effective 9/11/25 Epsolay cream pump 5% Updated age limit effective 10/1/25 Escitalopram capsule 15 mg Updated criteria, age and quantity limits effective 9/29/25 Exxua tablet, ER titration pack All Updated criteria effective 9/29/25 Finacea foam, gel 15% Updated age limit effective 10/1/25 Gabapentin ER (Generic for Gralise ) tablet All Updated quantity limit effective 10/10/25 Ibsrela tablet 50 mg Updated age limit effective 10/1/25 Isturisa tablet 1 mg Updated age limit effective 11/10/25 Ivermectin and brand Soolantra cream 1% Updated age limit effective 10/1/25 Jantoven tablet All Updated criteria effective 10/1/25 Jascayd tablet All Updated age and quantity limits effective 10/7/25 Koselugo capsule AllUpdated age and quantity limits effective 10/17/25Kymbee (Generic for Emflaza ) tablet All Updated age limit effective 11/7/25 Leqembi Iqlik injection 360 mg/ 1.8 mL Updated age and quantity limits effective 9/8/25 Linezolid in 0.9% Sodium Chloride IV solution bag 600 mg/ 300 mL Updated quantity limit effective11/5/25 Linzess capsule 145 mcg Updated age limit effective 11/10/25 Lisdexamfetamine (Generic for Vyvanse ) capsule 10 mg, 20 mg Updated criteria effective 9/16/25 Lurasidone (Generic for Latuda ) tablet All Updated age limit effective 8/20/25 Lynkuet capsule All Updated age and quantity limits effective 10/24/25 Lyrica oral solution 20 mg/mL Updated age limit effective 8/29/25 Mavyret pellet packet, tablet All Updated quantity limit effective 10/29/25 Metrocream cream 0.75% Updated age limit effective 10/1/25 Metrogel topical gel 1% Updated age limit effective 10/1/25 Metronidazole and brand MetroLotion topical lotion 0.75% Updated age limit effective 10/1/25 Minimed Instinct Sensor N/A Updated quantity limit effective 10/6/25 Mirvaso gel pump 0.33% Updated age limit effective 10/1/25 CareSourcePASSE.com Product Name Dose(s) Notes Modeyso capsule All Updated age and quantity limits effective 8/11/25 Neurontin capsule 400 mg Updated to remove criteria effective 10/1/25 Noritate cream 1% Updated age limit effective 10/1/25 Nypozi syringe 300 mcg/ 0.5 mL Updated quantity limit effective 10/20/25 Onapgo cartridge 98 mg/ 20 mL Updated criteria effective 10/7/25 OneNatal Rx prenatal tablet All Updated age limit effective 11/5/25 and quantity limit effective 8/18/25 Orlynvah tablet 500-500 mg Updated age limit effective 9/12/25 and quantity limit effective 10/1/25 Oseltamivir (Generic for Tamiflu ) suspension 6 mg/mL Updated age limit effective 10/1/25 Otezla XR tablet 75 mg Updated quantity limit effective 9/29/25 Otulfi vial 45 mg/ 0.5 mL Updated age limit effective 9/18/25 Pazopanib (Generic for Votrient ) tablet 400 mg Updated quantity limit effective 11/5/25 Primacare softgel capsule All Updated quantity limit effective 11/3/25 and age limit effective 11/5/25 Pyquvi oral suspension 22.75 mg/mL Updated age limit effective 9/8/25 Relistor syringe, tablet, vial All Updated age limit effective 10/1/25 Rhapsido tablet All Updated quantity limit effective 10/6/25 and age limit effective 10/7/25 Rhofade cream 1% Updated age limit effective 10/1/25 Rosadan cream, gel 0.75% Updated age limit effective 10/1/25 Selarsdi vial 45 mg/ 0.5 mL Updated age limit effective 10/16/25 Simponi syringe All Updated age limit effective 10/10/25 Skytrofa cartridge Multiple Updated quantity limit, all strengths and updated age limit for 7.6 mg, 9.1 mg, 11 mg and 13.3 mg strengthsSodium Oxybate solution 0.5 g/mL Updated age limit effective 9/18/25CareSourcePASSE.com Product Name Dose(s) Notes Sofosbuvir-Velpatasvir and brand Epclusa pellet packet, tablet All Updated quantity limit effective 10/1/25 Starjemza syringe, vial All Updated age limit effective 11/10/25 Stoboclo syringe 60 mg/mL Updated age limit effective 10/1/25 Subvenite suspension 10mg/mL Updated age limit effective 11/10/25 Sunosi tablet All Updated age limit effective 10/1/25 Tonmya sublingual tablet All Updated age limit 10/24/25 Tremfya syringe, pen, pen induction pack All Updated age limit effective 10/10/25 Tyvaso DPI inhalation powder 80mcg Updated quantity limit effective 11/1/25 Tyzavan IV solution bag All Updated quantity limit effective 10/27/25 Ustekinumab-AAUZ (Biosimilar to Otulfi ) syringe All Updated age limit effective 11/10/25 Viberzi tablet All Updated age limit effective 10/1/25 Vyscoxa suspension All Updated quantity limit effective 10/31/25 Wakix tablet All Updated age limit effective 9/18/25 Wayrilz tablet 400 mg Updated age and quantity limits effective 9/3/25 Xeljanz tablet All Updated age limit effective 10/31/25 Xerava vial All Updated quantity limit effective 10/15/25 Xyrem oral solution 500 mg/mL Updated age limit effective 9/18/25 Zoryve cream 0.05% Updated quantity limit effective 10/6/25 & age limit effective 10/17/25 Zurnai autoinjector 1.5 mg/ 0.5 mL Updated age and quantity limit effective 9/8/25 CareSourcePASSE.com What should you do? First, talk to your prescriber. There are a few ways you and your prescriber can find medication information:You can look on our website at CareSourcePASSE.com . On the Members page, under Tools & Resources click on Find My Prescriptions. Or, call Member Services at 1-833-230-2005 (TDD/TTY: 711) . We are here to help. Member Services is open Monday through Friday, 8 a.m. to 5 p.m. Central Time (CT). Sincerely, CareSource PASSE AR-PAS-M-1135300-V.17 DHS Approved: 2/23 /2022
CareSource.comRe: Summary of PDL Changes Effective February 1, 2026 Dear CareSource Member, Your health care is our priority. We are writing to tell you that on February 1, 2026 , CareSource will change its Preferred Drug List (PDL). A PDL is a list of preferred drugs. Dear CareSource Member, Your health care is our priority. We are writing to tell you that on February 1, 2026, CareSource will change its Preferred Drug List (PDL). A PDL is a list of preferred drugs. THE FOLLOWING MEDICINES WILL BE NON-PREFERRED ON THE PDL EFFECTIVE FEBRUARY 1, 2026 Brand Name Generic Name Strength(s) NotesAricept Donepezil hydrochloride All strengthsExelon Rivastigmine All strengths Namenda XR Memantine hydrochloride All strengths of capsule Namenda XR Memantine hydrochloride 7/14/21/28mg titration pack Adlarity Donepezil hydrochloride All strengths Step therapy added Memantine hydrochloride/donepezil hydrochlorideAll strengths Step therapy added Namzaric Memantine hydrochloride/ donepezil hydrochloride All strengths Step therapy added Zunveyl Benzgalantamine gluconate All strengths Step therapy added Ativan Lorazepam All strengths of injection Klonopin Clonazepam All strengths Valium Diazepam All strengths Xanax Alprazolam All strengths of immediate release tablet Xanax XR Alprazolam All strengthsBucapsol Buspirone hydrochloride All strengths Step therapy added Igalmi Dexmedetomidine hydrochloride All strengths Loreev XR Lorazepam All strengths Meprobamate All strengths Step therapy addedCelexa Citalopram hydrobromide All strengthsCymbalta Duloxetine hydrochloride All strengths Effexor XR Venlafaxine hydrochloride All strengths CareSource.com Brand Name Generic Name Strength(s) Notes Forfivo XL Bupropion hydrochloride 450mg tablet Lexapro Escitalopram oxalate All strengths Paxil Paroxetine hydrochloride All strengths of immediate release tablet Paxil CR Paroxetine hydrochloride All strengthsPaxil Paroxetine hydrochloride 10mg/5ml oral suspension Anafranil Clomipramine hydrochloride All strengths Nardil Phenelzine sulfate 15mg tablet Phenelzine 15mg tablet Step therapy addedNorpramin Desipramine hydrochlorideAll strengths Pamelor Nortriptyline hydrochloride All strengths Parnate Tranylcypromine sulfate 10mg tablet Tranylcypromine sulfate 10mg tablet Step therapy addedRemeron SoltabMirtazapine All strengths Remeron Mirtazapine All strengths Wellbutrin SR Bupropion hydrochloride All strengths Emsam Selegiline All strengths Step therapy added Marplan Isocarboxazid 10mg tablet Step therapy added Bupropion HCL XL (generic Forfivo XL)450mg tablet Step therapy addedCitalopram hydrobromide 30mg capsule Step therapy addedDrizalmaSprinkle DR Duloxetine hydrochloride All strengths Step therapy added Escitalopram oxalate 15mg capsule Quantity limit added; step therapy added; prior authorization updateExxua Gepirone hydrochloride All strengths Quantity limit added; age limit added; step therapy addedFluvoxamine ER All strengths Step therapy addedRaldesy Trazodone hydrochloride 10mg/ml oral solution Step therapy addedSertraline All strengths of capsule Step therapy addedSpravato Esketamine hydrochloride All strengthsTrimipramine maleate All strengths Step therapy addedAbilify Aripiprazole All strengthsClozaril Clozapine All strengths Geodon Ziprasidone hydrochloride All strengths of capsule CareSource.com Brand Name Generic Name Strength(s) Notes Geodon Ziprasidone mesylate 20mg/ml intramuscular solution Haldol DecanoateHaloperidol decanoate All strengths of intramuscular solution Invega Paliperidone All strengths of tabletLatuda Lurasidone hydrochloride All strengths Risperdal Risperidone 1mg/ml oral solution Risperdal Risperidone All strengths of tablet Saphris Asenapine maleate All strengths of sublingual tablet Seroquel Quetiapine fumarate All strengths of immediate release tablet Seroquel XR Quetiapine fumarate All strengths of extended release tablet Symbyax Olanzapine/fluoxetine hydrochlorideAll strengths Zyprexa Olanzapine 10mg vial Zyprexa Olanzapine All strengths of tablet Zyprexa Zydis Olanzapine All strengths of orally disintegrating tablet Lithobid Lithium carbonate 300mg extended release tabletCobenfy Xanomeline tartrate/trospium chloride All strengths Prior authorization update Fanapt Iloperidone All strengths of tablet Step therapy added Fanapt Iloperidone All strengths of titration pack Step therapy added Nuplazid Pimavanserin tartrate All strengths Prior authorization update Opipza Aripiprazole All strengths Step therapy added Pimozide All strengths Step therapy addedRisperidone microspheres (generic Risperdal Consta)All strengths Secuado Asenapine All strengths Step therapy added Versacloz Clozapine 50mg/ml oral suspension Step therapy added Ambien CR Zolpidem tartrate All strengths Ambien Zolpidem tartrate All strengths Doral Quazepam 15mg tablet Halcion Triazolam 0.25mg tablet Restoril Temazepam All strengths Rozerem Ramelteon 8mg tablet CareSource.com Brand Name Generic Name Strength(s) Notes Silenor Doxepin hydrochloride All strengths Dayvigo Lemborexant All strengths Step therapy added Edluar Zolpidem tartrate 5mg, 10mg sublingual tablets Step therapy added Flurazepam hydrochloride All strengths Step therapy addedHetlioz Tasimelteon 20mg capsule Prior authorization updateHetlioz LQ Tasimelteon 4mg/ml oral suspension Prior authorization update Quazepam 15mg tablet Step therapy addedQuviviq Daridorexant hydrochlorideAll strengths Step therapy added Tasimelteon 20mg capsule Prior authorization updateZolpidem tartrate 7.5mg capsule Step therapy addedZolpidem tartrate 1.75mg, 3.5mg sublingual tabletsStep therapy addedNuvigil Armodafinil All strengths Provigil Modafinil All strengths Sunosi Solriamfetol hydrochloride All strengths Prior authorization update Wakix Pitolisant hydrochloride All strengths Prior authorization update Sodium oxybate(generic Xyrem)0.5g/ml oral solution Prior authorization update Xywav Calcium/magnesium/ potassium/sodium oxybates 0.5g/ml oral solution Prior authorization update Catapres – TTS Clonidine All strengths Intuniv ER Guanfacine hydrochloride All strengths Strattera Atomoxetine hydrochloride All strengths Adderall Dextroamphetamine/ amphetamine All strengths of immediate release tablet Step therapy added Adderall XR Dextroamphetamine/ amphetamine All strengths of extended release capsule Step therapy added Aptensio XR Methylphenidate hydrochloride All strengths Step therapy added Concerta ER Methylphenidate hydrochloride All strengths Step therapy added Desoxyn Methamphetamine 5mg tablet Step therapy added CareSource.com Brand Name Generic Name Strength(s) Notes hydrochloride Dexedrine Spansule Dextroamphetamine sulfate All strengths Step therapy added Evekeo Amphetamine sulfate All strengths of tablet Step therapy added Focalin Dexmethylphenidate hydrochloride All strengths of immediate release tablet Step therapy added Focalin XR Dexmethylphenidate hydrochloride All strengths Step therapy added Metadate CD Methylphenidate hydrochloride All strengths Step therapy added Methylin Methylphenidate hydrochloride All strengths Step therapy added Procentra Dextroamphetamine sulfate 5mg/5ml oral solution Step therapy added Ritalin Methylphenidate hydrochloride All strengths Step therapy added Ritalin LA Methylphenidate hydrochloride All strengths Step therapy added Zenzedi Dextroamphetamine sulfate All strengths Step therapy added Amphetamine ER ODT (generic AdzenysXR-ODT)All strengths Dextroamphetamine-amphetamine ER (generic Mydayis ER) All strengths Step therapy added Mydayis Dextroamphetamine/ amphetamine All strengths Step therapy added Adzenys XR – ODT Amphetamine All strengths Step therapy added Cotempla XR-ODT Methylphenidate All strengths Step therapy added Lisdexamfetamine dimesylateAll strengths of capsuleLisdexamfetaminedimesylateAll strengths of chewable tablet Step therapy added Methylphenidatehydrochloride ER (generic Aptensio XR)All strengths Step therapy added Methylphenidate (generic Daytrana)All strengthsRelexxii Methylphenidate hydrochlorideAll strengths Step therapy added Xelstrym Dextroamphetamine All strengths Step therapy added CareSource.com Brand Name Generic Name Strength(s) Notes Depakote DR Divalproex sodium All strengths Depakote ER Divalproex sodium All strengths Gabapentin solution All strengths Prior authorization updateGabarone Gabapentin All strengths Step therapy addedLamictal Lamotrigine All strengths of chewable tablet Prior authorization update Lamictal ODT Lamotrigine All strengths of orally disintegrating tablet except kit Lamictal Lamotrigine All strengths of immediate release tablet except kit Lamictal XR Lamotrigine All strengths of extended release tabletsLamotrigine IR All strengths of kit Prior authorization updateLamotrigine ODT All strengths of kit Prior authorization updateKeppra Levetiracetam 500mg/5ml injection Prior authorization updateKeppra Levetiracetam 100mg/ml oral solution Prior authorization update Keppra Levetiracetam All strengths of immediate release tablet Prior authorization update Keppra XR Levetiracetam All strengths of extended release tablet Prior authorization update Onfi Clobazam 2.5mg/ml suspension Prior authorization update Onfi Clobazam All strengths of tablet Prior authorization update Oxcarbazepine ER All strengths of extendedrelease tabletPrior authorization update Pregabalin 20mg/ml solution Prior authorization updateSubvenite Lamotrigine All strengths of tabletSubvenite Lamotrigine All strengths of kit Prior authorization update Sympazan Clobazam All strengths Step therapy added Vyscoxa Celecoxib 10mg/ml suspension Step therapy added Zurnai Nalmefene hydrochloride 1.5mg/0.5ml injection Topamax Sprinkle Topiramate All strengths CareSource.com Brand Name Generic Name Strength(s) Notes Topamax Topiramate All strengths of immediate release tablet Topiramate ER(generic Trokendi) All strengths Topiramate 25mg/ml solutionTrileptal Oxcarbazepine All strengths of immediate release tablet Prior authorization update Trileptal Oxcarbazepine 300mg/5ml suspension Prior authorization update Tonmya Cyclobenzaprine hydrochloride 2.8mg sublingual tablets Quantity limit added; step therapy added Bildyos Denosumab-nxxp 60mg/ml injection Prior authorization update Bilprevda Denosumab-nxxp 120mg/1.7ml injection Prior authorization update Bomyntra Denosumab-bnht 120mg/1.7ml injection Prior authorization update; step therapy added Osenvelt Denosumab-bmwo 120mg/1.7ml injection Prior authorization update; step therapy added Conexxence Denosumab-bnht 60mg/ml injection Prior authorization update; step therapy addedStoboclo Denosumab-bmwo 60mg/ml injection Prior authorization update; step therapy added Brynovin Sitagliptin hydrochloride 25mg/ml solution Step therapy added Janumet XR Sitagliptin phosphate/ metformin hydrochloride All strengths Step therapy added Sogroya Somapacitan-beco All strengths Prior authorization update; step therapy added Insulin lispro 100 unit/ml vialMerilog Insulin aspart-szjj 100 unit/ml pen and vialLynkuet Elinzanetant 60mg capsule Prior authorization update Andembry Autoinjector Garadacimab-gxii 200mg/1.2ml injection Dawnzera Donidalorsen sodium 80mg/0.8ml injection Haegarda C1 esterase inhibitor (human) All strengths Nypozi Filgrastim-txid All strengths CareSource.com Brand Name Generic Name Strength(s) Notes Ryzneuta Efbemalenograstim alfa-vuwx 20mg/ml injection Tryptyr Acoltremon 0.003% eye drops Prior authorization update; quantity limit added Natroba Spinosad 0.9% topical suspension Pruradik Crotamiton 10% lotion Anzupgo Delgocitinib 2% cream Prior authorization update; quantity limit addedZoryve Roflumilast 0.05% cream Prior authorization update; quantity limit added; age limit added Pristiq ER Desvenlafaxine succinate All strengths Prozac Fluoxetine hydrochloride All strengths Viibryd Vilazodone hydrochloride All strengths Zoloft Sertraline hydrochloride All strengths of tablet Zoloft Sertraline hydrochloride 20mg/ml oral concentrate THE FOLLOWING MEDICINES WILL BE PREFERRED ON THE PDL EFFECTIVE FEBRUARY 1, 2026 Brand Name Generic Name Strength(s) NotesVtama Tapinarof 1% cream Prior authorization updateSitagliptin/metforminhydrochloride(generic Zituvimet XR) All strengths Prior authorization update; step therapy added Humulin NKwikPen Insulin NPH 100 unit/ml kwikpen Novolog Mix 70/30 Insulin aspart protamine/ insulin aspart 100 unit/ml pen and vial Humalog Insulin lispro 100 unit/ml vialNovolog Insulin aspart 100 unit/ml pen and vial Glyxambi Empagliflozin/linagliptin All strengths Step therapy removedEliquis Sprinkle Apixaban 0.15mg capsule Quantity limit added; step therapy added Eliquis PKT Apixaban All strengths of tablet for suspension Quantity limit added; step therapy added Cinryze C1 esterase inhibitor (human) 500unit vial Orladeyo Berotralstat hydrochloride All strengths Takhzyro Lanadelumab-flyo All strengths CareSource.com Brand Name Generic Name Strength(s) Notes Spinosad 0.9% topical suspensionBrixadi Buprenorphine All strengths Prior authorization update THE FOLLOWING MEDICINES HAVE A CHANGE IN STATUS EFFECTIVE FEBRUARY 1, 2026 Brand Name Generic Name Strength(s) NotesCitalopram hydrobromide All strengths of oral solution Step therapy added Escitalopram oxalate All strengths of oralsolutionStep therapy added Fluoxetine hydrochloride 20mg/5ml oral solution Step therapy addedNortriptyline 10mg/5ml oral solution Step therapy addedParoxetine hydrochloride 10mg/5ml oralsuspensionStep therapy added Sertraline hydrochloride 20mg/ml oral concentrateStep therapy addedAripiprazole ODT All strengths Step therapy addedAripiprazole 1mg/ml solution Step therapy addedClozapine ODT All strengths Step therapy addedLithium citrate 8meq/5ml oral solution Step therapy addedRisperidone ODT All strengths Step therapy addedRisperidone 1mg/ml oral solution Step therapy addedGalantamine hydrobromide4mg/ml oral solution Step therapy addedQelbree Viloxazine hydrochloride All strengths Step therapy added Dextroamphetamine sulfate5mg/5ml oral solution Step therapy addedJornay PM Methylphenidate hydrochloride All strengths Step therapy added Vyvanse Lisdexamfetamine dimesylate All strengths of chewable tablet Step therapy added Carbaglu Carglumic acid 200mg tablet Prior authorization update Carglumic acid 200mg tablet Prior authorization updatePheburane Sodium phenylbutyrate 483mg/gram Prior authorization updateSodium phenylbutyrate All strengths of powder and tabletPrior authorization updateRavicti Glycerol phenylbutyrate 1.1gram/ml Prior authorization update Olpruva Sodium phenylbutyrate All strengths Prior authorization CareSource.com Brand Name Generic Name Strength(s) Notes update; age limit update Ngenla Somatrogon-ghla All strengths Prior authorization update; step therapy update Skytrofa Lonapegsomatropin-tcgd All strengths Prior authorization update; age limit removed Androderm Testosterone All strengths Removed from Statewide Uniform Preferred Drug List (SUPDL) Eucrisa Crisaborole 2% ointment Prior authorization update; quantity limit added Opzelura Ruxolitinib phosphate 1.5% cream Prior authorization update; age limit added Zoryve Roflumilast 0.15% and 0.3% cream Prior authorization update; quantity limit update Zoryve Roflumilast 0.3% foam Prior authorization update; quantity limit update Topiramate ER sprinkle (generic Qudexy)All strengths Step therapy addedAnzemet Dolasetron mesylate 50mg tablet Step therapy added Granisetron hydrochloride 1 mg tablet Step therapy addedGranisetron hydrochloride solution for injection All strengths Step therapy added Palonosetron hydrochlorideAll strengths Step therapy addedSancuso Granisetron 3.1mg/24hr patch Step therapy update Sustol Granisetron 10mg/0.4ml injection Step therapy added Erygel Erythromycin 2% gel Removed from SUPDL Jubbonti Denosumab-bbdz 60mg/ml injection Prior authorization update; step therapy added Prolia Denosumab 60mg/ml injection Prior authorization update; step therapy added Wyost Denosumab-bbdz 120mg/1.7ml injection Prior authorization update; step therapy added Xgeva Denosumab 120mg/1.7ml injection Prior authorization update; step therapy CareSource.com Brand Name Generic Name Strength(s) Notes added Conjugated estrogens (genericPremarin)All strengths of tablet Prior authorization update Estrace Estradiol All strengths of tablet Removed from SUPDL Abilify Mycite Aripiprazole All strengths Removed from SUPDL Perseris ER Risperidone All strengths Removed from SUPDL Rykindo ER Risperidone microspheres All strengths Removed from SUPDL Qtern Dapagliflozin/saxagliptin hydrochloride All strengths Step therapy update Steglujan Ertugliflozin/sitagliptin phosphate All strengths Step therapy update Glycerol phenylbutyrate (generic Ravicti)1.1gram/ml Prior authorization updatePimecrolimus 1% cream Prior authorization updateTacrolimus All strengths of ointment Prior authorization updateEnbumyst Bumetanide 0.5mg nasal spray Prior authorization update; quantity limit added Rezdiffra Resmetirom All strengths Prior authorization update What should you do? First, talk to your prescriber. There may be other medicines on the CareSource PDL that you can take instead. There are a few ways you and your prescriber can find medicines: You can look on our website at CareSource.com/IN . On the Members page, go to Tools & Resources, choose your plan and click on Find My Prescriptions. Or, call Member Services at 1-844-607-2829 (TTY: 1-800-743-3333 or 711) . We are here to help. Member Services is open Monday through Friday, 8 a.m. to 8 p.m., Eastern Time (ET)/7 a.m. to 7 p.m. Central Time (CT). Sincerely, CareSource IN-MED-M-3083118-V.7; First Use: 4/29/2025 OMPP Approved: 4/29/2025
Actualizacin del Manual del Afiliado 2025 La informacin ha cambiado desde que se imprimi y public el Manual del Afiliado 2025 en CareSource.com . Si desea presentar una queja por correo, visite CareSource.com/es/ga/members/tools resour ces/forms/medicaid. Luego, el ija "Formulario de queja/apelacin". Complete e imprima el formulario. El lugar al que lo enve depender del tipo de queja que presente. Existe una nueva direccin para las quejas odontolgicas. Quejas odontolgicas CareSource Attn: Member Appeal and Grievance P.O. Box 1251 Milwaukee, WI 53201 Todas las dems quejas CareSource Attn: Member Grievances P.O. Box 1947 Dayton, OH 45401 Puede presentar una queja en lnea o por telfono. Puede hacerlo para cualquier queja, incluidas las quejas odontolgicas. Llame al: 1-855-202-0729 (TTY : 711) Visite : MyLife.CareSource.com Para obtener ms informacin sobre quejas, consulte las pginas 52 y 53 de su Manual del Afiliado. Tiene preguntas? Llame a Servicios para Afiliados al 1-855-202-0729 (TTY: 711). Nuestro horario de atencin es de lunes a viernes, de 7 a. m. a 7 p. m., hora del este (ET). GA-MED-M-4484156-SPA Aprobado por D CH: 11/17/2025
CareSource.comAsunto: Resumen de los cambios a la PDL en vigor a partir del 1 de enero de 2026 Estimado/a afiliado/a de CareSource: Su atencin mdica es nuestra prioridad. Por este motivo, le escribimos para informarle que el 1 de enero de 2026, CareSource cambiar la Lista de medicamentos preferidos (Preferred Drug List, PDL). Una PDL es una lista de medicamentos preferidos. LOS SIGUIENTES MEDICAMENTOS TENDRN UN CAMBIO EN SU ESTADO A PARTIR DEL 1 DE ENERO DE 2026.Nombre de marcaNombre genrico Dosis Notas Tryptyr Acoltremn Gotas para los ojos al 0.003 % Se actualiz la autorizacin previa; se agreg el lmite de cantidad. Widaplik Telmisartn/ Amlodipina/ Indapamida Todas las concentraciones Se actualiz la autorizacin previa; se agreg el lmite de cantidad. Anzupgo Delgocitinib Crema al 2 % Se actualiz la autorizacin previa; se agreg el lmite de cantidad. Andembry Garadacimab – gxii Inyeccin de 200 mg/1.2 ml Se actualiz la autorizacin previa; se agreg el lmite de cantidad. Harliku Nitisinona Comprimido de 2 mg Se actualiz la autorizacin previa; se agreg el lmite de cantidad. Yeztugo Lenacapavir sdico Inyeccin de 463.5 mg/1.5 ml Se actualiz la autorizacin previa; beneficio mdico. Ekterly Sebetralstat Comprimido de 300 mg Se actualiz la autorizacin previa; se agreg el lmite de cantidad. Sylvant Siltuximab Todas las concentraciones Se actualiz la autorizacin previa; beneficio mdico. Radicava, Radicava ORS Edaravona Todas las concentraciones Se actualiz la autorizacin previa. Firazyr Acetato de icatibant Inyeccin de 30 mg/3 ml Se actualiz la autorizacin previa. Acetato de Icatibant, SajazirInyeccin de 30 mg/3 mlSe actualiz la autorizacin previa. Cinryze Inhibidor de C1 esterasa Inyeccin, 500 unidades Se actualiz el lmite de cantidad. Rivfloza Nedosirn sdico Todas las concentraciones Se actualiz la autorizacin previa; se actualiz el lmite de edad. CareSource.com Nombre de marca Nombre genrico Dosis Notas Xiaflex Colagenasa de Clostridium histolyticum Inyeccin de 0.9 mg Se actualiz la autorizacin previa. Gamifant Emapalumab – lzsg Todas las concentraciones Se actualiz la autorizacin previa. Apretude Cabotegravir Inyeccin de 600 mg/3 ml Se actualiz la autorizacin previa. Tavalisse Fostamatinib disdico Todas las concentraciones Se actualiz la autorizacin previa. Triumeq Abacavir/Doluteg ravir/Lamivudina Comprimidos de 600 mg, 50 mg, 300 mg Se elimin la autorizacin previa. Yutrepia Treprostinil sdico Todas las concentraciones Se agreg el lmite de cantidad. Vykat XR Diazxido colina Todas las concentraciones Se actualiz la autorizacin previa; se actualiz el lmite de cantidad. Ebglyss Lebrikizumab – lbkz 250 mg/2 ml, inyectable Se actualiz la autorizacin previa. Nemluvio Nemolizumab-ilto 30 mg, inyectable Se actualiz la autorizacin previa. Alvaiz Eltrombopag colina Todas las concentraciones Se actualiz la autorizacin previa; se agreg el lmite de cantidad. Doptelet Maleato de avatrombopag Todas las concentraciones Se actualiz la autorizacin previa; se actualiz el lmite de cantidad para comprimidos; se agreg el lmite de cantidad para cpsulas dispersables. Mulpleta Lusutrombopag Comprimidos de 3 mg Se actualiz la autorizacin previa; se actualiz el lmite de cantidad. Nplate Romiplostim Todas las concentraciones Se actualiz la autorizacin previa; se agreg el lmite de cantidad. Promacta Eltrombopag olamina Todas las concentraciones Se actualiz la autorizacin previa; se actualiz el lmite de cantidad. Wayrilz Rilzabrutinib Comprimidos de 400 mg Se actualiz la autorizacin previa; se agreg el lmite de cantidad. Diclofenaco epolaminaParches al 1.3 %Se actualiz la terapia escalonada. CareSource.com Qu debe hacer?Primero, hable con la persona que le receta los medicamentos. Es posible que haya otros medicamentos en la PDL de CareSource que puede tomar en su lugar. Hay varias maneras en que usted o la persona que receta pueden encontrar medicamentos: Puede consultar nuestro sitio web en CareSource.com/IN . En la pgina Afiliados, vaya a Herramientas y recursos, elija su plan y haga clic en Encontrar mis medicamentos con receta. Llame a Servicios para Afiliados al 1-844-607-2829 (TTY: 1-800-743-3333 o 711). Estamos aqu para ayudarle. El horario de atencin de Servicios para Afiliados es de lunes a viernes, de 8 a. m. a 8 p. m, hora del este (ET) y de 7 a. m. a 7 p. m., hora central (CT). Atentamente, CareSource IN-MED-M -3083118-V.6-SPA; Primer uso: 4/29/2025 Aprobado por OMPP: 4/29/2025
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