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Indiana Marketplace Plans

Medical Policies

Medical policies offer guidance on determination of medical necessity and appropriateness of care for approved benefits. Benefit determinations and coverage decisions are subject to all the terms and conditions of CareSource including eligibility, definitions, specific inclusions or exclusions, and applicable state or federal laws.

The medical policies do not constitute medical advice or medical care. Treating health care providers are solely responsible for diagnosis, treatment and medical advice. CareSource is not responsible for, does not provide, and does not represent itself as a provider of medical care.

Policies are considered guidelines and are not intended to infer benefits or coverage for a specific member. Benefit determinations are based on the specific facts of each member’s case. If a service or supply is not eligible for coverage, a member and the treating provider may proceed with that service or supply after receiving a denial from CareSource for the requested non-covered service.

Existing clinical policies are regularly reviewed and updated. New policies are added as appropriate while previous versions are maintained in the policy archive. These policy changes are maintained on this site.

The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.

Current Medical Policies

PolicyEffective Date
17 Alpha Hydroxyprogesterone Caproate (Makena)
Acute In-Patient Detoxification (Opioid) Prior Authorization Criteria
Alpha 1-Proteinase Inhibitor Injection
Applied Behavior Analysis (ABA) Therapy
Autoimmune Diseases Biologic Therapies
Belimumab (Benlysta)
Biologic Cholesterol Agents
Biologic and Other Ophthalmologic Agents
Botulinum Toxin Injection
Breast Reconstruction Surgery Following Mastectomy
Breast Reduction Surgery
Calcium Regulators (Reclast, Zometa, Boniva, Prolia, Forteo, Xgeva)
Colony Stimulating Factors
Continuous Glucose Monitoring Systems (CGMS)
Cystic Fibrosis
Cytomegalovirus Immune Globulin Intravenous (Cytogam)
Dispense as Written (DAW) Requests
Electrodiagnostic Testing: Nerve Conduction and Needle Electromyography Automated Nerve Conduction Studies
Emergency Response Systems
Enzyme Replacement Therapy and Agents: Aldurazyme, Cerezyme, Eleprase, Vpriv, Fabrazyme, Lumizyme/Myozyme, Naglazyme, Elelyso, Zavesca, Cerdelga, Vimizim
Epidural Steroid Injections (Interlaminar, Transforaminal or Caudal Epidural Injections)
Facet Medial Branch Nerve Blocks
Facet Neurotomy
Genetic Testing, Genetic Screening and Genetic Counseling
Hematopoietic Growth Factor (Epoetin alfa, Darbenpoetin alfa, Tbo-filgrastim, Pegfilgrastim, Filgrastim and Sargramostim)
Hepatitis C - Oral
Hereditary Angioedema and Pharmacotherapy
Home Infusion Therapy
Home Medication Dispenser Devices
Hyaluronic Acid Derivative Injection
Idiopathic Pulmonary Fibrosis: Esbriet (Pirfenidone), OFEV (Nintedanib)
Immune (Idiopathic) Thrombocytopenia Purpura (ITP)
Immune Globulin (Gammaked, Carimune, Carimune NF, Flebogamma, Flebogamma DIF, Gamastan S/D, Gammagard Liquid, Gammagard S/D Less IgA, Gammaplex, Gamunex, Hizentra, Octagam, Polygam, Privigen)
Inflammatory Bowel Disease: Biological Therapies
Insulin Infusion Pump Therapy for Diabetes
Lipid Testing in Assessing Cardiovascular (CV) Risk
Lupron DEPOT
Mastectomy for Gynecomastia
Medication Assisted Therapy (MAT): Suboxone
Multiple Sclerosis Therapy Class
Nutritional Supplement
Obesity Surgery
Obesity Surgery in Adolescents
Omalizumab (Xolair) – Xolair/Nucala
Palivizumab (Synagis)
Pegylated and Non-Pegylated Interfeon (alfa-2a Pegasys, alfa-2b Pegintron, <em>i</em>nterferon alfa-2b Intron A)
Psoriasis: Biological Therapies
Pulmonary Arterial Hypertension
Rituxan (Rituximab)
Sacroiliac Joint Injection
Screening and Surveillance for Colorectal Cancer
Seizure Disorders (Repository Corticotropin Injection (H.P. Acthar Gel) and Vigabatrin (Sabril) Oral Solution and Tablets)
Serum Biomarker Panel Testing in Systemic Lupus Erythematosus and Rheumatoid Arthritis
Short Bowel Syndrome Policy (Gattex, Zorbitive
Somatropin Injection
Stab Phlebectomy
Trigger Point Injections

Archived Medical Policies