Pharmacy Policies
These pharmacy policies apply to provider administered drugs for our Ohio Medicaid plan, which are reimbursable by CareSource.
Claims for the drugs below are reimbursable by CareSource pursuant to Ohio Administrative Code (OAC) 5160-26-13. If the servicing (billing) provider is registered with the Ohio Department of Medicaid as a pharmacy, all pharmaceuticals must be approved and billed to the Single Pharmacy Benefit Manager, Gainwell Technologies. Claims for pharmaceuticals billed by a pharmacy to CareSource will be denied.
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
Current Pharmacy Policies
The following medications are managed under the Medical Benefit at CareSource. For medications payable through Gainwell Technologies, the Single Pharmacy Benefit Manager, please visit https://spbm.medicaid.ohio.gov/ or https://pharmacy.medicaid.ohio.gov/unified-pdl.
A
B
C
D
E
F
G
H
I
K
L
M
- MACI (autologous cultured chondrocytes)
- Macrilen (macimorelin)
- Macugen (pegaptanib)
- Medicaid Drug Rebate Program (MDRP) Coverage Rules - AC Reject
- Medical Necessity – Off Label
- Medical Necessity for DAW
- Medical Necessity for Non-Formulary Medications
- Mepsevii (vestronidase alfa-vjbk)
- Multi-ingredient Compound Policy
- Myobloc (rimabotulinumtoxinB)
N
O
P
R
S
- Saphnelo
- Scenesse (Afamelanotide)
- Signifor And Signifor LAR
- Simponi Aria (golimumab)
- Skyrizi
- Soliris (eculizumab)
- Somatostatin analogs (Injectable; First generation): Sandostatin (octreotide), Sandostatin LAR (octreotide), Somatuline Depot (lanreotide), Bynfezia Pen (octreotide)
- Somavert (pegvisomant)
- Spevigo (spesolimab-sbzo)
- Spinraza
- Spravato (esketamine)
- Supprelin LA (histrelin acetate)
- Susvimo (ranibizumab)
- Synagis
T
U
V
X
Y
Z
Ohio Department of Medicaid Unified Preferred Drug List
The following medications are managed under the Pharmacy Benefit, or Pharmacy and Medical Benefit both, at CareSource and are found within the Ohio Department of Medicaid’s current Unified Preferred Drug List. Therefore, these medications utilize criteria outlined within the Ohio Unified Preferred Drug List. Prescribers can access the UPDL documents online through ODM’s website by viewing the UPDL and UPDL criteria.