Pharmacy Policies
These pharmacy policies apply to the CareSource plan. The policies below are in PDF format.
Current Pharmacy Policies
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
A
B
C
D
E
F
G
H
I
J
K
L
M
- MACI (autologous cultured chondrocytes)
- Medicaid Drug Rebate Program (MDRP) Coverage Rules - AC Reject
- Medicaid Drug Rebate Program (MDRP) Coverage Rules - AC Reject
- Medical Benefit Medications
- Medical Necessity Off Label
- Medical Necessity – Off Label
- Medical Necessity for Non-Preferred Drugs
- Mepsevii (vestronidase alfa-vjbk)
- Mulpleta (lusutrombopag)
- Multi-ingredient Compound Policy
- Multi-ingredient Compound Policy
- Multi-Source Brand Policy
- Myalept (metreleptin )
- Mycapssa (octreotide)
N
O
P
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp]
- Palynziq (pegvaliase-pqpz)
- Panhematin (hemin for injection)
- PiaSky (crovalimab-akkz)
- Pombiliti (cipaglucosidase alfa-atga) and Opfolda (miglustat)
- Prevymis (letermovir)
- Procysbi and Cystagon (cysteamine bitartrate); Cystaran and Cystadrops (cysteamine hydrochloride solution)
- Promacta and Alvaiz (eltrombopag)
- Pulmozyme (dornase alfa inhalation solution)
R
S
- Scenesse (afamelanotide)
- Signifor, Signifor LAR (pasireotide)
- Single Dose Vial – Claims Modifiers
- Skysona (elivaldogene autotemcel)
- Sodium Phenylbutyrate (Buphenyl, Pheburane, Olpruva)
- Sohonos (palovarotene)
- Somatostatin analogs (Injectable; First generation): Sandostatin (octreotide), Sandostatin LAR (octreotide), Somatuline Depot (lanreotide), Bynfezia Pen (octreotide)
- Standard Medical Billing Guidance
- Sucraid (sacrosidase)
- Syfovre (pegcetacoplan)