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Medical Policies

The CareSource 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.

Policies are regularly reviewed, updated, withdrawn or added and therefore, subject to change. Please check back often for updates on CareSource's Medical Policies.

Specialty Pharmacy PA

CareSource changed its requirements on specialty pharmacy Prior Authorization (PA). CareSource uses evidence-based guidelines to ensure health care services or medications meet the standards of excellent medical practice and are the lowest cost alternative for the member. These new requirements ensure appropriate use of these medications. These medical policies are listed below.

Specialty pharmacy medications are listed in alphabetical order by brand name and generic name.

Prior Authorizations must include:

  • Please complete the Prior Authorization form
  • The J-code and NDC # must be submitted with the requested drugs. Please refer to the Medical Policy for most up-to-date NDC/J-codes for the medication you are requesting. Medical Policies are reviewed and updated annually.
  • Supporting Clinical Documentation


ABA Therapy


ABA Therapy
Accommodation During Transplant Surgery
Breast Reconstruction Surgery
Breast Reduction
Determinations with no Policy/UM
Emergency Response System
Experimental or Investigational Technologies
Inpatient Detoxification - Opiate
Keloid Repair
Medication Dispenser Policy
National and Local Coverage Determinations
Nutritional Supplement
Obesity Surgery
Obesity Surgery in Adolescents
Observation Care Criteria
Pain Management Interventional Procedures

Medical Policy Archives