CareSource Medicare (CareSource Advantage) Pharmacy Information

Before providing care or prescribing medicine for your patients, please review the CareSource Advantage 2009 Preferred Drug List or 2010 Preferred Drug List, the 2009 Preferred Drug List UPDATE or 2010 Preferred Drug List UPDATE, or print CareSource’s 2009 Medical Prior Authorization form or the 2010 Medical Prior Authorization form or 2009 Pharmacy Prior Authorization form or the 2010 Pharmacy Prior Authorization form.

Preferred Drug List (Formulary Medication)

The 2009 Preferred Drug List (Formulary) or the 2010 Preferred Drug List (Formulary) is the list of drugs that are covered as a pharmacy plan benefit for CareSource members. The CareSource Advantage formulary was selected in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. CareSource Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a CareSource Advantage network pharmacy, and other plan rules are followed.

Tiered Medications

The medications are categorized into four tiers: preferred generics (Tier 1), preferred brands (Tier 2), specialty or biological drugs (Tier 3), and non-preferred generics and brands (Tier 4). The member is responsible for the applicable drug co-payment or co-insurance.

Tiered Cost Sharing Exceptions

You may ask us to provide a higher level of coverage for your Part D drug. If your Part D drug is contained in our Tier 4, you may ask us to cover it at the cost-sharing amount that applies to drugs in the Tier 1 or Tier 2 instead.  This would lower the coinsurance/copayment amount you must pay for your Part D drug. Please note, if we grant your request to cover a Part D drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug.

A member must meet appropriate medical necessity criteria before the tiered cost sharing exceptions will be approved. To determine medical necessity, the CareSource Advantage Plan will verify, through the provider’s supporting statement(s) and/or standards documented in clinical guidelines adopted by the Plan, that all drugs in the lower preferred tiers:
1) Would not be as effective for the member as the requested drug,
2) Would have adverse effects for the member, or both.

Tiered cost sharing exception requests will be processed through CareSource’s Pharmacy Benefit Manager’s (PBM) prior authorization review process.

Pharmacy Prior Authorization

CareSource will process coverage determinations and exception requests in accordance with Medicare Part D regulations. Requests will be handled through the Prior Authorization review process. Prior authorization requires a drug to be “pre-approved” in order for it to be covered under a benefit plan.

The Prior Authorization staff will adhere to the CareSource Advantage CMS approved criteria. The PBM’s National Pharmacy and Therapeutics Committee establishes clinical guidelines, and other professionally recognized standards in reviewing each case, rendering a decision based on established protocols and guidelines.

Providers can submit prior authorization requests by phone or fax. Providers will be required to submit pertinent medical/drug history, prior treatment history, and any other necessary supporting clinical information with the request.  Standard requests will be reviewed and determinations will be made within 72 hours.  Expedited or urgent requests will be reviewed and determinations will be made in 24 hours. A request is considered urgent if the requestor believes that applying the standard process may seriously jeopardize the member’s life, health, or ability to regain maximum function.  Providers will be notified by phone or fax of the determination.

Prescribers or their designated agents may request authorization by one of the following mechanisms:
• Toll-free phone number: 1-800-390-7102
• Written request via fax: 1-866-950-9375 for oral medications and injectable/specialty medications

Formulary Exceptions

The 2009 Preferred Drug List (Formulary) or 2010 Preferred Drug List (Formulary) contains many commonly prescribed drugs. During the course of a plan member’s medical care, there may be instances when a member requires a non-formulary drug or a drug that has formulary limits or restrictions (e.g., step-therapy requirements, prior authorization, or quantity limits).

CareSource Advantage may approve an exception request for a non-formulary drug or a drug that has formulary limits or restrictions when medically necessary. To determine medical necessity, CareSource Advantage will verify through the provider’s supporting statement(s) and/or standards documented in clinical guidelines adopted by CareSource Advantage, that
• The member has tried and failed and/or has documented contradictions or intolerance to the equivalent formulary medications, and
• No other formulary agent is appropriate to treat the member’s condition.

Exception requests will be processed through CareSource Advantage’s Prior Authorization staff.

Pharmacy Management Program Exceptions

CareSource holds a contract with a Pharmacy Benefits Manager for adjudication of pharmacy claims.  Requests for pharmaceutical prior authorizations should be directed to CareSource at 1-800-390-7102 or fax to 1-866-930-0019. Follow the menu prompts to speak to a pharmacy coordinator. Prior authorization is required for brand name drugs when a generic drug is available. Prior authorization may also be required for other drugs.

To obtain a copy of CareSource’s preferred drug list, please contact CareSource at 1-800-390-7102, visit our website at www.caresource.com, or download the list to your PDA free of charge at www.ePocrates.com.

If you feel it is medically necessary for a member to have a non-preferred drug, please request an exception by forwarding information about the non-preferred drug to CareSource. You may fax the information toll-free to 1-866-930-0019 using the request form in the Forms section of the 2009 Provider Manual or the 2010 Provider Manual. Your request will be reviewed and a decision made within 24 hours of receipt. If the request is not authorized, you will be notified of the reason.

A pharmacist may request a 72-hour supply of medication on all non-preferred medications if clinically required after hours or for emergency situations. Drugs such as fertility and cosmetic medications are considered benefit exclusions and will not be considered.

For technical requests, you can reach the Pharmacy Benefits Manager at 1-866-668-0321. For prior authorization requests, call CareSource at 1-800-390-7102 or fax to 1-866-930-0019.

Preferred Drug List

CareSource utilizes a preferred drug list that is reviewed annually. Generic medications must be used when they are available. Participating CareSource physicians are notified annually of the drugs included in the preferred drug list. Drugs listed in the drug list are covered. In general, this includes:
• Most generic medications.
• Limited over-the-counter, medically necessary medications when prescribed in writing by a licensed medical practitioner.
• One generic 90-day smoking cessation treatment per year.

Formulary medications may require prior authorization, adherence to step-therapy criteria, or quantity limits. Step therapy requires that a first-line preferred medication which is generally accepted as therapeutically equivalent be tried before a second-line preferred or non-preferred medication. Quantity limits have been established on some drugs to align with recommended treatment courses and to help reduce overutilization and abuse. Exceptions to quantity limits may be granted with medical necessity as prescribed by a provider.

Non-covered medications include:
• Brand name drugs when a generic is available.
• Infertility, cosmetic purposes, or erectile dysfunction.
• Any drug that may be obtained without charge under other local, state or federal programs.
• Any drug labeled “Caution: Limited by federal law to investigational use”.

Injectable Drugs

Injectable drugs should be requested through CareSource or ordered from the injectable Pharmacy Benefits Management partner Caremark. Prior authorization must be obtained from CareSource at 1-800-390-7102 before contacting Caremark. Caremark provides specialty injectable medication to individuals with chronic illness requiring complex, high-cost treatment. To place injectable prescription orders by phone with Caremark, please call 1-800-378-5697 or fax to 1-800-278-0323.

Preferred Laboratory Provider

CareSource has partnered with Quest Diagnostics in a Preferred Provider relationship to capture laboratory results that support HEDIS and other quality initiatives. A complete list of Quest Diagnostics Patient Service Centers is available on their Website at www.questdiagnostics.com or call 1-800-444-0106, extension 1300.

For more information about the CareSource Advantage Pharmacy Management Program see the 2009 Provider Manual or the 2010 Provider Manual.