Pharmacy
CareSource's pharmacy program is managed through a contract with a Pharmacy Benefit Management (PBM) company. Through this PBM, we maintain a formulary of preferred drugs.
CareSource Medicaid Pharmacy Information
CareSource Medicare - CareSource Advantage® (HMO SNP) Pharmacy Information
Pharmacy Policy on Stolen Narcotics
Effective February 1, 2012, when a member is prescribed controlled substances and they are stolen:
- It will be the member’s responsibility to file a police report for the medications that were stolen
- The member must contact their prescribing provider to send CareSource the police report and a prior authorization (PA) request for the early refill
- Incomplete requests (missing police report and/or missing PA request) will result in a denial
- CareSource can put in a one-time override for the member for lost, spilled, or stolen maintenance medications or antibiotics.
Changes to Specialty Pharmacy PA in the Provider Setting
Effective June 15, 2011
Effective June 15, 2011, CareSource will change its requirements on specialty pharmacy Prior Authorization (PA). CareSource uses evidence-based guidelines to ensure health care services or medications meet the standards of excellent medical practice and are the lowest cost alternative for the member. These new requirements ensure appropriate use of these medications.
Specialty pharmacy medications are listed in alphabetical order by brand name and generic name.
Who will this affect?
Ohio Providers: Medical benefit for specialty drugs requiring PA beginning June 15, 2011.
Providers can also find more information by visiting our Medical Policies.
Providers can submit prior authorization for these medications by:
Phone: Specialty Pharmacy – 1-800-488-0134
Fax: Specialty Pharmacy – 1-888-399-0271
Online: Provider Portal
Specialty Pharmacy Prior Authorization Quick Reference Guide
CareSource has created a quick reference guide for providers submitting PA requests starting June 15.
Prior Authorizations must include:
- Please complete the Prior Authorization form
- The J-code and NDC # must be submitted with the requested drugs
- Supporting Clinical Documentation
Claims for the designated specialty medications must include:
- PA
- J-code
- NDC #
- Revenue code 636 if administered in the outpatient setting
Important Note: Dump codes are listed in red in the quick reference guide. Codes J3490, J390, J8499 must be billed with a NDC number in order for the claim to pay.