Pharmacy

CareSource® Dual Advantage™ (HMO SNP) provides prescription drug coverage and has an approved Drug Formulary. This benefit provides coverage for prescriptions obtained from a retail pharmacy, mail-order pharmacy or specialty pharmacy, as well as those that are administered in the patient’s home, including drugs administered through a home health agency.

CareSource uses evidence-based guidelines to ensure health care services and medications meet the standards of excellent medical practice and are the lowest cost alternative for the member. 

Restrictions & Limits

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

  • Prior Authorization
  • Step Therapy
  • Quantity Limits
Resources

Drug Formulary

Access updates to our Preferred Drug List (PDL)

Navigate 2024 Prior Authorization Criteria
Navigate 2023 Prior Authorization Criteria (12/07/2023) Last updated on 12/07/2023

CareSource requires you to get prior authorization for certain drugs. This means that you will need to get approval from CareSource before the prescription is filled. If you don’t get approval, CareSource may not cover the drug.

Navigate 2024 Step Therapy Criteria
Navigate 2023 Step Therapy Criteria (12/07/2023) Last updated on 12/07/2023

In some cases, CareSource requires you to first try certain drugs to treat a medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat the medical condition, CareSource may not cover Drug B unless you try Drug A first. If Drug A does not work for you, CareSource will then cover Drug B.

Resources

Pharmaceutical Management Materials

To learn more about how to use our pharmaceutical management procedures, look in the summary section of the formulary. CareSource provides pharmaceutical management procedures annually and after updates. Changes are made in writing by mail, fax or email or via the web. If you have any questions regarding our pharmaceutical management procedures, please call Clinical Pharmacy Services at 1-844-679-7865 from 8 a.m. to 6 p.m. Eastern Time (ET) Monday through Friday.

Contact Information for Coverage Decisions

Mail: Express Scripts
P.O. Box 66587
St. Louis, MO 63166-6587
Attn: Benefit Coverage Review Department

Phone: 1-800-416-1673

We are open 8 a.m. – 8 p.m. ET Monday through Friday, and from Oct. 1 – March 31 we are open the same hours 7 days a week.

Fax: 877-328-9660