Drug Formulary

To see what medicines CareSource covers, you can access our CareSource Marketplace Drug Formulary. You also can use the online Find My Prescriptions tool.

We want to make sure our members get the safest, most cost-effective drugs for their needs. We use evidence-based guidelines to make sure our formulary meets best medical practices.

Drug Formulary Changes

Effective monthly, there may be changes to our Drug Formulary. You can check the NavigateNotice of Formulary Changes to see if any of these changes affect the medicines you take.

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 makers’ recommended dosing, patient safety, associated state or federal laws, or the Food & Drug Administration (FDA) recommendations. The abbreviation “QL” is used in the Drug Formulary to show there is a quantity limit.

Step Therapy

Sometimes, CareSource will require a member to try a less expensive drug used to treat the same condition before “stepping up” to a medication that costs more. This is called step therapy. Certain drugs may only be covered if step therapy is met and in accordance with applicable state laws. The abbreviation “ST” is used in the Drug Formulary to show when Step Therapy is required.

Generic Substitution and Therapeutic Interchange

A pharmacy may provide a generic drug in place of a brand-name drug. This is called generic substitution. Members and health partners can expect the generic to produce the same effect and have the same safety profile as the brand-name drug. This is known as therapeutic interchange.

Generic drugs usually cost less than their brand-name equivalents.

In most instances, a brand-name drug for which a generic product becomes available will become non-formulary, with the generic product covered in its place, upon release of the generic product onto the market. However, the formulary document is subject to state-specific regulations and rules regarding generic substitution and mandatory generic rules apply where appropriate.

How to Request a Medicine not on the Formulary

Sometimes a member may have a drug allergy or intolerance. Or, a certain drug may not be effective for a member. In these cases, the member or the member’s representative may ask for an exception to drugs listed on the CareSource Marketplace Drug Formulary. The member or member’s representative can call Member Services to make the request, or complete the online Member Exception Request for Non-Formulary Medication

CareSource then reaches out to the provider to obtain the appropriate documentation. CareSource will provide a decision no later than 72 hours after the request is received, or within 24 hours if the member is suffering from a serious health condition. 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 will consider whether the requested drug is clinically appropriate.

Drug Safety Recalls

Sometimes, a drug manufacturer or the federal government issues drug recalls. To find out if a drug you take is being recalled, please check the listings on the U.S. Food & Drug Administration website.


DISCLAIMERS

CareSource is a Qualified Health Plan issuer in the Health Insurance Marketplace. This is not a Health Insurance Marketplace website. This website does not display all available Marketplace plans. To see all available Qualified Health Plan options available, go to www.healthcare.gov.

This website is subject to change at any time without prior notice. This website is intended only as general information and is not an offer or invitation to contract.

This is a solicitation for health insurance. CareSource Marketplace plans have exclusions, limitations, reductions and terms under which the policy may be continued in force or discontinued. Premiums, deductibles, coinsurance and copays may vary based upon individual circumstances and plan selection. Benefits and costs vary based upon plan selection. Not all plans and products offered by CareSource cover the same services and benefits. Covered services and benefits may vary for each plan. For costs and complete details of coverage, please review CareSource’s Evidence of Coverages and Schedules of Benefits documents at www.caresource.com/marketplace.

Specific policy benefits listed on this website are intended to be a summary of coverage and do not list or describe all the benefits covered under specific policies nor is every limitation, exclusion or reduction of benefits listed. The overview of benefits, coverage and member cost shares are based on benefits being received from an in-network provider. To be eligible for reimbursement, all health care services must be provided by an in-network provider, except when applicable federal and state law or the applicable Evidence of Coverage for each policy provide otherwise.

Rates, benefits, premiums, deductibles, co-payments, co-insurance, and out of pocket expenses may vary based upon a variety of factors, including but not limited to, age, county of residence, smoking status, and level of policy selected.

References to CareSource pertain to each individual company or other CareSource affiliated companies, such as CareSource, CareSource Kentucky Co., CareSource Indiana Inc., CareSource West Virginia Co., and CareSource Georgia, Co. Each company is a separate entity and is not responsible for another’s financial condition or contractual obligations.

CareSource does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.

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Last updated 10/23/2019