Pharmacy
Prescription drugs
With CareSource Advantage® (HMO SNP), we offer more of the prescription drugs you need. We provide access to more than 63,000 pharmacies, which are listed in the 2012 Pharmacy Directory.
CareSource Advantage uses a 2012 Preferred Drug List (formulary) to show the drugs we prefer that your doctor prescribe. Some drugs are not covered by Medicare prescription drug coverage. Some drugs may also have amount limits or require step therapy. For a list of prescription drugs requiring Prior Authorization, please select the 2012 Drugs requiring Prior Authorization. Also for a list of the drugs that require step therapy, please select the 2012 Drugs requiring Step Therapy.
CareSource will coordinate your medical care and your prescription drug needs so you can focus on other things in your life. CareSource's Medicare Prescription Drug Benefit is only available to members of the CareSource Advantage plan.
We know you have a lot of questions about prescription drug benefits. Here are some questions we are often asked:
How do I find out if my drug is covered?
You may view our Preferred Drug List (formulary) by clicking the 2012 Preferred Drug List (formulary) or call Member Services at 1-877-725-4581, Monday through Friday, 8 a.m. to 8 p.m. (TTY users should call 1-800-649-3777 or 711).
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How do I find a pharmacy?
You may look in the 2012 Pharmacy Directory. Or, for the most recent listing, click on Find a Pharmacy to find a pharmacy location near you. Just type in your address and the system will tell you the network pharmacy locations near your home.
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Will the Preferred Drug List (formulary) change?
Yes, please see the 2012 Preferred Drug List Changes as the 2012 Preferred Drug List (formulary) may change from month to month.
We may add or remove drugs from the formulary during the year. Changes in the formulary may affect which drugs are covered and how much you will pay when filling your prescription. If we remove drugs from the formulary, or add Prior Authorizations, quantity limits and/or step therapy restrictions on a drug, and you are taking the drug affected by the change, we will notify you of the change at least 60 days before the date that the change becomes effective. If we don't notify you of the change in advance, you will get a 60-day supply of the drug when you request a refill of the drug. However, if a drug is removed from our formulary because the drug has been recalled from the market, we will not give 60 days notice before removing the drug from the formulary. Instead, we will remove the drug from our formulary immediately and notify members about the change as soon as possible.
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Do you offer generic drugs?
CareSource Advantage covers both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.
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Will I have a co-pay for my prescription drugs?
Yes, co-pays may vary by drug. See your 2012 Summary of Benefits for more information.
If you think you are being charged an incorrect co-payment for your prescription drugs, please contact Member Services at 1-877-725-4581, Monday through Friday, 8 a.m. to 8 p.m. (TTY users should call 1-800-649-3777 or 711). You may also click here for information regarding the Centers for Medicaid and Medicare Services' (CMS) Best Available Evidence Process.
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How do I find out if I am eligible to receive additional help to pay for my prescription drug costs?
You may be able to get extra help to pay for your prescription drug premium and costs. To see if you qualify for getting extra help, call:
*For more premium information, see LIS Premium Summary Chart.
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What is a network pharmacy?
We call the pharmacies listed in the 2012 Pharmacy Directory our "network pharmacies" because we have agreements with them to provide prescription drugs to our members. A network pharmacy is a pharmacy where members can get prescription drug benefits provided by CareSource.
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What is Step Therapy?
In Step Therapy, certain drugs are put into groups to help your doctor decide which drugs to prescribe. The steps in the process are:
- Step 1: Front-line drugs are generic drugs proven safe, effective and affordable. These drugs should be tried first because they can provide the same health benefit as more expensive drugs, at a lower cost.
- Step 2: Back-up drugs are lower-cost brand-name drugs such as those you see advertised on TV.
- Step 3: Back-up drugs that are higher-cost brand drugs. Back-up drugs may be used when lower cost alternatives do not meet a members needs.
For a list of the drugs that require step therapy, please select the 2012 Plan Step Therapy Criteria.
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What are Quantity Limits?
For certain drugs, CareSource Advantage (HMO SNP) limits the amount of the drug that CareSource Advantage will cover. For example, CareSource Advantage provides 8 vials per 30 days per prescription for Imitrex Injection. This may be in addition to a standard one-month or three-month supply.
You can find out if your drug has any additional requirements or limits by looking in the 2012 Preferred Drug List (formulary).
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How will the Transition Period requirement be handled?
2012
For those members who are new to the plan and aren’t in a long-term care facility: We will cover a temporary supply of your drug one time only during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
For those who are a new member and a resident in a long-term care facility: We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The first supply will be for a maximum of 31 days, or less if your prescription is written for fewer days. If needed, we will cover additional refills during your first 90 days in the plan.
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Do you require Prior Authorization?
If your doctor feels it is medically necessary for you to have a drug that is not on the list, he or she will need to ask for a Prior Authorization. Providers can use the Pharmacy Coverage Determination form to make a Prior Authorization Request. This form can be completed and submitted online. For a list of prescription drugs requiring Prior Authorization, please select the 2012 Drugs requiring Prior Authorization.
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Are the doctors in your network aware of your prescription drug benefits?
Yes, participating CareSource physicians have been notified in writing of the drugs included on the 2012 Preferred Drug List (formulary) as well as the special procedures set up for urgent medication requests.
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What if I have to use an out-of-network pharmacy?
In most cases, your prescriptions are covered under CareSource Advantage only if they are filled at a network pharmacy. Please see the 2012 Pharmacy Directory for more information. Please contact the plan for details regarding out-of-network prescription drug fills.
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How do I file a grievance or appeal a decision about my prescription drug benefits?
A grievance is a complaint that shows you are not satisfied with the plan or pharmacy's service. To find out how to file a 2012 grievance, appeal a decision, or 2012 request an exception, or a 2012 redetermination please call Member Services at 1-877-725-4581, Monday through Friday, 8 a.m. to 8 p.m. (TTY users should call 1-800-649-3777 or 711).
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How do I find out about CareSource's Quality Assurance Program?
CareSource has a thorough Quality Assurance Program. To find out more, please view the 2012 Quality Assurance Policy.
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H0141_MIMSNP607
CMS Approved 12/20/2011