MedicaidCoverageMedium impact
[Ohio] Pharmacy Policy Updates December 2025
CareSource·OH · Oncology, Hematology, Rheumatology +4 more·Pharmacy
Effective date
Jan 1, 2026
We identified it
May 9, 2026
Summary
CareSource Ohio Medicaid is updating pharmacy policies for 13 medications effective January 1, 2026, including 10 revised policies, 2 new policies (Sylvant and Yeztugo), 1 archived policy (Yutiq), and 1 revised policy for Gender Identity Hormone Therapy. The specific clinical or billing changes within each policy are not detailed in this notification; billing teams must review individual policy documents to identify prior authorization requirements, coverage criteria, or billing code changes.
Action Required
By December 20, 2025: Billing team and clinical staff must access and review each of the 13 updated pharmacy policies on CareSource.com (Providers > Tools & Resources > Provider Policies > select Ohio Medicaid > Pharmacy). For each medication, document: (1) any new or changed prior authorization requirements, (2) covered indications and dosing limits, (3) applicable billing/HCPCS codes, and (4) any clinical documentation requirements. Update billing system logic, prior authorization workflows, and provider order entry templates accordingly. Pay special attention to the 2 new policies (Sylvant/Siltuximab and Yeztugo/Lenacapavir) and note that Yutiq is now archived and should not be billed. Communicate changes to all prescribers and pharmacy staff. Failure to implement correct prior authorization and coverage criteria will result in claim denials or patient billing issues beginning January 1, 2026.