As a Qualified Health Plan in the Health Insurance Marketplace, CareSource provides prescription drug coverage. This benefit provides coverage for prescriptions obtained from a retail pharmacy, mail-order pharmacy or specialty pharmacy; and 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. These requirements ensure appropriate use of these medications.


Members may be required to pay cost-share for prescription drugs. Cost-share amounts vary based on plan and medication. View the Navigate Provider Manual for more information, or call us at 1-833-230-2101.

Drug Formulary

CareSource updates the formulary regularly. Visit the Drug Formulary page for more information.

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 drug to produce the same effect and have the same safety profile as the brand name drug. If a brand name product is requested when an equivalent generic drug is available, you may need to request prior authorization. Also, members may pay additional costs for brand name drugs when an equivalent generic drug is available.

Prior Authorization

Some drugs may require prior authorization before they will be covered. Refer to the drug formulary to determine which drugs need prior authorization. 

Prior authorization requests for medications covered under outpatient Medical Benefit for Marketplace may be submitted or by fax. In emergent situations, requests may be accepted via phone.

Drugs Covered Under Pharmacy Benefit

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

Prior authorization requests covered under outpatient Pharmacy benefit for Marketplace may be submitted three ways:

  • Pharmacy Benefit Fax: 1-866-930-0019
  • Electronic submission through CoverMyMeds or SureScripts portals
  • Phone: 1-833-230-2101

Opioid drugs will always require prior authorization in the following circumstances:

  • More than 90 days of therapy in the last 365 days
  • More than 80 morphine milligram equivalents per day
  • Concurrent therapy with benzodiazepines
  • All extended-release opioids require prior authorization

Specialty Medications

Most Specialty Medications require prior authorization from CareSource. For medications billed to CareSource under medical benefit, reference the Procedure Code Lookup Tool under Quick Links. Access our Pharmacy Policies for criteria by selecting Policies from Quick Links for more information.

Specialty Pharmacy Prior authorization requests for marketplace may be submitted as follows:


  • 1-866-930-0019 (pharmacy benefit)
  • 1-888-399-0271 (medical benefit)

Electronic submission:

  • CoverMyMeds or SureScripts portals (pharmacy benefit)
  • CareSource Provider Portal (medical benefit)

Phone: 1-833-230-2101

Prior Authorization Forms


CareSource pharmacy and medical policies include drug-specific and therapy class policies to be used as a guide when determining health care coverage for our members with benefit plans covering prescription drugs. 

The policies are written for those prescription drugs that are non-formulary, formulary with prior authorization or require step therapy. The policy is a tool to be interpreted in conjunction with the member’s specific benefit plan. Access pharmacy policies by selecting Policies from the Quick Links for more information. 


CareSource has an exception process that allows the member or the member’s representative to make a request for an exception. Reasons for exceptions may include intolerance to drugs, allergies to drugs, or inadequate/inappropriate response to drugs listed on the 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 48 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.

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, applicable state and federal laws, or the Food & Drug Administration (FDA) recommendations.

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 in accordance with applicable state and federal law. 

Therapeutic Interchange

A member might have a drug allergy or intolerance, or a certain drug might not be effective. If a non-formulary agent is requested, the provider will need to submit a prior authorization request. This is called therapeutic interchange.

Home Infusion Therapy

For most home infusion therapy services, CareSource does 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.


Maximum Allowable Cost (MAC)

CareSource is dedicated to providing the most current MAC pricing for drug reimbursement.

MAC pricing can be accessed through the secure ESI Provider Portal

MAC Appeals can be completed through the portal and by following the Navigate ESI Appeals Process instructions.

Pharmaceutical Management Procedures

To learn more about how to use our pharmaceutical management procedures, look in the drug 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 1-833-230-2101.

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.