Pharmacy
Prescription drugs
With CareSource Advantage®, we offer more of the prescription drugs you need. We provide access to more than 52,000 pharmacies, which are listed in the 2009 Pharmacy Directory or the 2010 Pharmacy Directory.
CareSource Advantage uses a 2009 Preferred Drug List (formulary) or the 2010 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.
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 2009 Preferred Drug List (formulary) or the 2010 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 1-866-649-3777 or 711).
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How do I find a pharmacy?
You may look in the 2009 Pharmacy Directory or the 2010 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 check this web site for updates as the 2009 Preferred Drug List (formulary) or the 2010 Preferred Drug List (formulary) may change from month to month.
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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 2009 Summary of Benefits or the 2010 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 1-866-649-3777 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 2009 Pharmacy Directory or the 2010 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.
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How will the Transition Period requirement be handled?
As a Part D plan, CareSource allows a one time 34 day, prescription of a non-formulary drug to members who are new to 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 2009 prior authorization form or the 2010 prior authorization form to make a Prior Authorization request. For a list of prescription drugs requiring Prior Authorization, please select the 2009 Drugs requiring Prior Authorization or the 2010 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 2009 Preferred Drug List (formulary) or the 2010 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. CareSource will allow three out-of-network fills per drug per calendar year. Out-of-network pharmacy use beyond the three fills only applies in an emergency. If you continue to go to an out-of-network pharmacy, you may have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. Please see the 2009 Pharmacy Directory or the 2010 Pharmacy Directory or more information.
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Can the formulary change?
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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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 2009 grievance, appeal a decision or 2010 grievance, appeal a decision, or 2009 request an exception or 2010 request an exception or 2009 redetermination or 2010 redetermination please call Member Services at 1-877-725-4581, Monday through Friday, 8 a.m. to 8 p.m. (TTY users should call 1-866-649-3777 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 2009 Quality Assurance Program or the 2010 Quality Assurance Program.
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