The comprehensive formulary is a list of all drugs covered under your CareSource Dual Advantage plan. Additionally, CareSource provides monthly formulary updates to keep information current.
For information about changes to our formulary, please review the Notice of Formulary Changes below. For the most up-to-date formulary information, use our online Find My Prescription tool.
Visit the Plan Documents page to view important documents about prescription drug benefits.
We feel it is important that you have continued access to the formulary drugs that were available when you chose our plan for the remainder of the coverage year, except for cases in which you can save additional money or we can ensure your safety.
Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. If these changes occur, no prior notification will be provided before the change is made.
Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year.
If the following changes are made to our formulary:
- A drug is removed from our formulary
- Prior authorization, quantity limits and/or step therapy restrictions are added for a drug
- A drug is moved to a higher cost-sharing tier
We will notify affected members at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug. At this time the member will receive a 30-day supply of the drug.
If the FDA deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.
Review our Notice of Formulary Changes (Updated 12/01/2022) for information about updates that have been made to our plan’s formulary.
Why Choose Generics?
CareSource covers both brand-name drugs and generic drugs. Generic drugs have the same active ingredients as brand-name drugs. 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.
You will notice the formulary offers generic substitutions for brand-name drugs when possible. By choosing generics, you will still get effective, safe treatment and you may save money.
For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. This ensures our members use these drugs in a safe way. The types of additional requirements are listed below:
- Prior Authorization Criteria – For certain drugs, your doctor will need to contact us before you can fill your prescription.
- 2023 Prior Authorization Criteria (11/10/2022) Last updated on 11/10/2022
- Step Therapy Criteria – For certain drugs, we require you to first try another drug to treat your medical condition before we will cover the drug initially prescribed by your physician.
- 2023 Step Therapy Criteria (11/10/2022) Last updated on 11/10/2022
What Are My Options
Can I receive coverage for drugs not on the formulary?
Yes, if you believe you are entitled to payment or benefits on a certain drug, you can request a coverage determination. A coverage determination is a decision made by CareSource regarding payment for a Part D drug or exceptions to our formulary. If your coverage determination is denied, you can appeal the decision by asking for a redetermination of the original request.
Full details on coverage determinations and appeals can be found in the Evidence of Coverage (Chapter 9, section 6). Find this and other documents on our Plan Documents page. For more information about exceptions, appeals and complaints review your Part D Prescription Drug Plan Rights.
What if I am taking a drug not on the formulary?
CareSource Dual Advantage plan features a drug transition policy. Learn more by visiting our Drug Transition Policy webpage.
What if I need help managing my medications?
A Medication Therapy Management (MTM) program is a service we offer at no cost. This program is not a benefit. The program is designed to help you learn about your Part D medications, prevent or address medication-related problems, decrease costs and stick to your treatment plan. Learn more about MTM.
You can get many of your Medicare Part D drugs sent to your home through mail. There is no charge for shipping if you use regular delivery.
You must use the in-network providers except in emergency or urgent care situations. If you obtain routine care from out-of-network-providers, neither Medicare nor CareSource will be responsible for the costs, unless specifically authorized by CareSource. You must use in-network pharmacies to access the prescription drug benefit, except under non-routine circumstances when you cannot reasonably use an in-network pharmacy.