Pharmacy

CareSource RxInnovations™ partners with Express Scripts® (ESI) to administer the pharmacy program. Working with ESI as our pharmacy innovation partner, we maintain a Preferred Drug List (PDL) and quarterly PDL updates.

Formulary or Preferred Drug List (PDL)

The Preferred Drug List (PDL), also known as a formulary, is a list of drugs that are preferred under the plan. Visit the Drug Formulary page for more information.

For ESI network and contracting questions, please contact Express Scripts directly by visiting the ESI Pharmacy Portal or email NetworkCompliance@express-scripts.com.

Prior Authorization

Some drugs may require prior authorization before they will be covered. Refer to the Drug Formulary page to determine which drugs need prior authorization.

Medications billed under a member’s medical benefit may also require prior authorization. Refer to the Authorization Requirements for Medications Under the Medical Benefit (coming soon).

For all prior authorization decisions (standard or urgent), CareSource PASSE provides notice to the provider and member as expeditiously as the member’s health condition requires. Please specify if you believe the request is urgent. The CareSource PASSE Pharmacy Department will review all prior authorization requests and provide a decision no later than 24 hours after the request is received.

Medical Benefit Fax: 888-399-0271

Prior authorization requests for medications covered under the outpatient medical benefit for CareSource PASSE may be submitted electronically through the Provider Portal or by fax.

Pharmacy Benefit Fax: 866-930-0019

Prior authorization requests for medications covered under the pharmacy benefit may be submitted electronically through the CoverMyMeds® or Surescripts prior authorization portals or by fax. In emergent situations, requests may be accepted via phone.

Phone: 1-833-230-2100 (Phone requests are not for routine prior authorization requests.)

You may submit requests using the following forms:

Specialty Pharmacy

Most specialty pharmacy medications require a prior authorization prior to being covered. Refer to the PDL and pharmacy policies by selecting Provider Policies from the Quick Links for more information.

You can submit specialty pharmacy prior authorization requests online or via fax (phone requests cannot be accepted under most circumstances for specialty medications). In emergent situations, requests will be accepted via phone.

  • Online: Provider Portal (coming soon)
  • Fax (Pharmacy Benefit): 866-930-0019
  • Fax (Medical Benefit): 888-399-0271
  • Phone: 1-833-230-2100

Specialty pharmacy prior authorizations must include:

Claims for specialty medications must include:

  • Prior authorization form
  • HCPCS/CPT Code
  • NDC number
  • Revenue code 636 (if administered in the outpatient setting)

Note: Codes J3490, J3590, J8499 must be billed with an NDC number in order for the claim to pay.

Policies

CareSource PASSE pharmacy and medical policies include drug-specific and therapy class policies to be used as a guide when determining prescription coverage for our members.

The policies are written for those prescription drugs that are non-preferred, preferred with prior authorization or require step therapy. The policy is a tool to be interpreted in conjunction with the member’s specific benefit plan.

Exceptions

CareSource PASSE has an exception process that allows the prescriber, member or the member’s representative to request coverage of a drug that is not on the PDL. Reasons for exceptions may include intolerance, allergies or contraindications to drugs listed on the formulary.

An exception can be requested via fax or an electronic submission portal such as CoverMyMeds®. Phone submissions will also be accepted if the member is suffering from a serious condition that requires urgent treatment. Members may also submit a formulary exception via phone, fax or online.

The CareSource PASSE Pharmacy department will review all exception requests and provide a decision no later than 24 hours after the request is received. Providers may be asked to provide written clinical documentation as to why a member needs an exception. In determining whether an exception will be given, CareSource PASSE will consider whether the requested drug is clinically appropriate.

You must give us a written statement that explains the medical reasons for requesting an exception. To ensure there is no delay in the review process, be sure to include this medical information when you ask for the exception.

Generic Substitution

A pharmacy will provide a generic drug if available in place of a brand name drug. This is called generic substitution. Members and providers can expect the generic to produce the same effect and have the same safety profile as the brand name drug. If a brand name product is requested when a generic equivalent is available, you will need to request a prior authorization and explain why the member cannot use the generic medication.

CareSource PASSE follows Arkansas Medicaid’s defined preferences to brand medications on the state’s PDL.

Quantity Limits

Some drugs have limits on how much can be given to a member at one time. Quantity limits may be based on several factors such as drug manufacturers’ recommended dosing, patient safety or the Food & Drug Administration (FDA) recommendations.

Step Therapy

Sometimes, CareSource PASSE will require a member to try one drug used to treat the same condition before “stepping up” to a different medication that costs more. This is called step therapy. Certain drugs may only be covered if step therapy is met.

Medication Therapy Management

CareSource PASSE offers a medication therapy management (MTM) program for all members. MTM services allow local pharmacists to work collaboratively with physicians and other prescribers to enhance quality of care, improve medication compliance, address medication needs and provide health care to patients in a cost-effective manner. You may be contacted by a pharmacist to discuss your patients’ medications. We also encourage members to talk with their pharmacist about their medications, as we want to make sure they are getting the best results from the medications they are taking.

Home Infusion Therapy

For most traditional home infusion therapy services, CareSource PASSE may not require participating preferred providers to submit prior authorization requests.

If you are not a participating preferred provider, you must submit a prior authorization request before rendering home infusion therapy services. Check the Authorization Requirements for Medications Under the Medical Benefit (coming soon) to determine if a prior authorization is required for the medication.

Pharmacy Claims Submission

Please visit the ESI Pharmacy Portal for claims information, including:

  • Payer sheet
  • Compound prescription requirements
  • Prospective DUR response requirements

Paper claim submission requirements can be found Navigatehere.

For questions regarding filling a prescription, please contact Express Scripts toll free at 1-800-922-1557 for the general pharmacy help desk or at 1-800-716-2939 for the dedicated CareSource PASSE line. These lines are answered 24 hours a day, 7 days a week.

Drug Pricing and Pricing Appeals

CareSource PASSE is dedicated to working with our Pharmacy Benefits Manager (PBM), Express Scripts, and our Pharmacy partners to provide the most current National Average Drug Acquisition Cost (NADAC) pricing, as applicable, for drug reimbursement.

NADAC pricing can be accessed on Medicaid.gov. Pricing information can also be accessed through the secure Express Scripts Provider Portal.

Drug pricing appeals can be completed through the portal and by following the NavigateExpress Scripts Appeal Process.

Drug Safety Recalls

Sometimes, a drug manufacturer or the federal government issues drug recalls. To find out if a drug you have prescribed to a patient is being recalled, please check the listings on the FDA website.