MedicaidCoverageMedium impact
[Ohio] Pharmacy Policy Updates September 2025
CareSource·OH · Pharmacy, Ophthalmology, Hematology +5 more·Pharmacy
Effective date
Oct 1, 2025
We identified it
May 9, 2026
Summary
CareSource Ohio Medicaid is updating 38 pharmacy policies effective October 1, 2025, including 5 new drug policies (ENCELTO, IMAAVY, ERT for Gaucher Disease, ZEVASKYN, and Medical Benefit Medications), 26 revised policies for specialty medications, and 7 annual reviews with no changes. The majority of changes involve specialty pharmaceuticals for rare diseases, gene therapies, and cell therapies. Billing teams must review individual policy details to identify any prior authorization, coverage restrictions, or documentation requirement changes that may affect claim submission.
Action Required
By September 30, 2025: Billing team must access CareSource.com Providers > Tools & Resources > Provider Policies, select Ohio Medicaid Pharmacy section, and review the full text of all 38 updated policies listed in this notification. For each NEW policy (ENCELTO, IMAAVY, ERT for Gaucher Disease, ZEVASKYN, Medical Benefit Medications) and each REVISED policy, identify: (1) new or changed prior authorization requirements, (2) coverage criteria or restrictions, (3) documentation requirements, and (4) any billing code mappings. Update internal pharmacy authorization workflows, prior auth templates, and billing system rules accordingly. Communicate changes to prescribing providers and pharmacy staff. Starting October 1, 2025, apply all updated policies to new claims. Failure to implement required prior authorizations or coverage restrictions will result in claim denials.