MedicaidCoverageHigh impact
[Indiana] Pharmacy Policy Updates December 2024
CareSource·IN · Pharmacy·Pharmacy
Effective date
Jan 1, 2025
We identified it
May 9, 2026
Summary
CareSource Indiana Medicaid is updating 34 pharmacy policies effective January 1, 2025, including 6 new drug policies (KISUNLA, IQIRVO, PYRUKYND, RYPLAZIM, VOYDEYA, XOLREMDI) and revisions to existing specialty pharmaceutical coverage rules, medical necessity criteria, and billing modifiers. The billing team must review and implement changes to prior authorization requirements, coverage determinations, and claim submission procedures for these specialty drugs.
Action Required
By December 20, 2024: Billing team must (1) Access all 34 updated pharmacy policies via CareSource.com > Providers > Tools & Resources > Provider Policies > Select Indiana Medicaid > Pharmacy; (2) Review the 6 NEW policies (KISUNLA/donanemab, IQIRVO/elafibranor, PYRUKYND/mitapivat, RYPLAZIM/plasminogen, VOYDEYA/danicopan, XOLREMDI/mavorixafor) to identify new prior authorization requirements, dosing limits, and coverage criteria; (3) Update billing software and prior authorization workflows for all 34 affected drugs; (4) Update provider documentation requirements and templates for medical necessity, DAW (Dispense as Written), neutral medications, and multi-ingredient compounds; (5) Revise single dose vial claim modifier procedures per updated guidance; (6) Train billing staff on MDRP (Medicaid Drug Rebate Program) AC reject coverage rules and lost/stolen/damaged/vacation medication supply policies; (7) Communicate changes to clinical staff prescribing these specialty drugs. Failure to implement changes by January 1, 2025 will result in claim denials for non-compliant submissions.