MedicaidPrior AuthMedium impact
[Indiana] Pharmacy Policy Updates August 2025
CareSource·IN · Pharmacy, Neurology, Ophthalmology +8 more·Pharmacy
Effective date
Oct 1, 2025
We identified it
May 9, 2026
Summary
CareSource Indiana Medicaid is updating pharmacy policies for 40 specialty medications effective October 1, 2025. Changes include new policies for 8 medications, revised policies for 17 medications (including prior authorization criteria changes), archived policies that now follow fee-for-service prior authorization, and policies with no clinical criteria updates. Billing teams must review individual medication policies to identify specific prior authorization requirements and coverage changes for affected drugs.
Action Required
By September 15, 2025: Billing team and pharmacy staff must review the full individual policy documents for all 40 medications listed at CareSource.com > Providers > Tools & Resources > Provider Policies to identify specific prior authorization requirements, coverage criteria, and billing implications. For the 8 NEW policies (CTEXLI, Enzyme Replacement Therapy for Gaucher Disease, GOMEKLI, IMAAVY, ROMVIMZA, VAFSEO, VANRAFIA, VYKAT XR) and 17 REVISED policies, update prior authorization protocols in billing system. For ONPATTRO and WAINUA (archived policies now following fee-for-service criteria), implement fee-for-service prior authorization requirements. Document any changes to encounter forms, prior authorization templates, and staff training materials. Notify prescribing providers of new/revised medication policies affecting their patients. Failure to implement required prior authorizations will result in claim denials for Indiana Medicaid members.