MedicaidCoverageHigh impact
[Ohio] Pharmacy Policy Updates June 2025
CareSource·OH · Oncology, Hematology, Infectious Disease +6 more·Pharmacy
Effective date
Jul 1, 2025
We identified it
May 9, 2026
Summary
CareSource Ohio Medicaid is updating pharmacy policies for 23 specialty medications effective July 1, 2025. Changes include 2 new policies (Aucatzyl, Prevymis) and 21 revised policies affecting CAR-T therapies, rare disease treatments, and specialty biologics. Billing teams must review each drug's specific coverage criteria, prior authorization requirements, and documentation standards to ensure claims process correctly.
Action Required
By June 28, 2025: Billing team must access each of the 23 updated pharmacy policies on CareSource.com (Providers > Tools & Resources > Provider Policies > Ohio > Pharmacy) and document any changes to prior authorization requirements, coverage criteria, and medical necessity documentation. Update billing system rules and staff training materials for: ABECMA, Aucatzyl, Breyanzi, Carvykti, Somatostatin Analogs, Krystexxa, Kymriah, Leqembi, Maci, Prevymis, Spravato, Tecartus, Tzield, Yescarta, Alpha1-Proteinase Inhibitor, Radicava (both formulations), Onpattro, Tepezza, Cortrophin Gel, Zinplava, Syfovre, Qalsody, Gamastan, Rebyota, and Enjaymo. Providers must be notified of new documentation requirements. Claims submitted after July 1, 2025 without compliance to updated policies will be denied.