MedicaidCoverageHigh impact
[Indiana] September 2026 Pharmacy Policy Updates
CareSource·IN · Pharmacy, Oncology, Genetics +2 more·Pharmacy
Effective date
Nov 1, 2026
We identified it
Sep 2, 2026
Summary
CareSource Indiana Medicaid is updating 16 specialty pharmacy policies effective November 1, 2026. Changes include 4 new policies (Aqvesme, Avlayah, Loargys, and others), 7 revised policies with updated coverage criteria, 4 annual reviews with no clinical updates, and 1 archived policy (Mycapssa). Billing teams must review each policy's specific prior authorization, coverage limits, and documentation requirements before the effective date.
Action Required
Before November 1, 2026: Pharmacy and billing teams must access and review all 16 updated pharmacy policies on CareSource.com (Providers > Tools & Resources > Provider Policies > select Indiana Medicaid > Pharmacy). For each REVISED policy (Alpha1-Proteinase Inhibitor, Elaprase, Imcivree, Immune Globulin, Kanuma, Lerochol, Oncology Regimens, Vimizim, Vyvgart), document specific changes to prior authorization requirements, dosing limits, and medical necessity criteria. For each NEW policy (Aqvesme, Avlayah, Loargys), establish new prior authorization workflows and update billing system edits. Update pharmacy staff and providers on coverage changes. For Mycapssa (archived), cease all billing for this medication on Indiana Medicaid effective November 1, 2026. Failure to comply with updated requirements will result in claim denials and potential payment recoupments.