CareSource Medicaid Pharmacy Information

Effective October 1, 2011, CareSource will cover all medically necessary Medicaid-covered prescription drugs and medical supplies. This change affects everyone who gets health care through an Ohio Medicaid managed care plan.

QUICK TOOLS

Ohio's Managed Care Plans (MCPs) collaborated with Ohio Medicaid to create a more standardized formulary and a single set of utilization-management guidelines to make it easier for providers to work with the MCPs. While CareSource offers all medically necessary Medicaid-covered prescription drugs, we use a Preferred Drug List (PDL). These are drugs that we prefer our providers prescribe and does not represent all of the drugs covered by Ohio Medicaid.

Preferred Drug List

Please refer to the PDL when prescribing for CareSource members. This guide lists the preferred drugs within the most commonly prescribed therapeutic categories. (It is not a complete listing of all drugs that we cover.) The medications included in the PDL are reviewed and approved by the Pharmacy and Therapeutics committee, which includes practicing physicians and pharmacists from the CareSource provider community.

Prior Authorizations

We may require providers to submit information to us to explain why a specific medication and/or a certain amount of a medication may be needed. We must approve the request before a member can get the medication. If your patient needs an alternative medication that is not covered, you can request a review by submitting a prior authorization (PA) request.

To obtain Prior Authorization:

To obtain prior authorization, you can:

Reasons why we may prior authorize a drug include:

  • There is a generic or pharmacy alternative drug available
  • The drug can be misused/abused
  • There are other drugs that must be tried first
  • There is a specific diagnosis that is the manufactured labeled indication

Some drugs may have quantity limits and some drugs are never covered like weight loss, erectile dysfunction, infertility and cosmetic drugs.

Please Note: Our PDL and Medications That Require Prior Authorization can change so it is important for you to check this information periodically. You can also find out medication coverage status on ePocrates and Fingertip Formulary applications that can be downloaded on your mobile device.

Emergency Prescriptions

In an emergency, State and Federal law require that a pharmacy dispense a 72-hour supply (3 days) of a medication for any patient awaiting a prior authorization decision. CareSource will reimburse the pharmacy for the 72-hour supply at contracted rates for those prescriptions, whether or not the request is ultimately approved or denied.

Over the Counter Medications

CareSource covers many over the counter medications as part of the pharmacy benefit. The CareSource member must have a written prescription for over the counter medications.

Medical Supplies

Some medical supplies are also covered under the CareSource Pharmacy benefit, including diabetic supplies, spacers, peak flow meters and condoms. These supplies are available at your patient's pharmacy and covered by CareSource when presented with a written prescription.

To support member access and convenience, most enteral, incontinent and wound care supplies are covered for a first fill at retail pharmacies. Subsequent fills at the retail pharmacy will require prior authorization.

Specialty Medications

Specialty medications that are administered in a provider setting such as a physician office, hospital outpatient department, clinic, dialysis center, or infusion center will be billed through the pharmacy or medical department. If using a Jcode to bill the medical benefit, an NDC number is required when utilizing miscellaneous codes J3490, J3590 and J7799. Please Note: The coding information above only applies to CFC and ABD Medicaid members.

e-Prescribing (CareSource Advantage Program only)

Help reduce errors and improve patient safety

As a health care leader, CareSource is committed to making it easier for you to work with us. e-Prescribing refers to the use of a secure network so that prescribers can share patient prescription information.

Benefits of e-Prescribing:

  • You can check the CareSource formulary at the time of patient contact
  • Save time and money with fewer pharmacy calls and faxes
  • Fewer medication errors and harmful drug allergies or interactions
  • Better health outcomes, improved overall quality of care and enhanced patient safety
  • Automated prescription renewal and authorization

e-Prescribe and receive higher reimbursement from Medicare

Physicians who prescribe for Medicare patients and who adopt qualified electronic prescribing systems are eligible for an increase in reimbursement, starting January 1, 2009. Medicare will provide eligible physicians with a two percent incentive payment for reporting years 2009 and 2010, a one percent incentive payment for reporting years 2011 and 2012, and a one-half percent incentive payment in reporting year 2013. A physician could receive up to a 1.5 percent pay boost for 2009.

For more information about the Medicare e-Prescribing incentive program you can download "Medicare's Practical Guide to the e-Prescribing Incentive Program" or visit the Medicare e-Prescribing incentive program information page.