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 copays for prescription drugs. Copay amounts vary based on plan and medication. Coinsurance is applied for specialty pharmacy. View the provider manual for more information, or call us at 1-833-230-2155.
CareSource updates the formulary regularly. Visit the Drug Formulary page for more information.
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 may need to request prior authorization. Also, members may pay additional costs for brand name drugs when a generic equivalent is available.
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 may be submitted online, over the phone or by fax.
Online: Provider Portal
Medications billed on the medical benefit may also require prior authorization. Please check the Authorization Requirements for Medications Under the Medical Benefit. For all prior authorization decisions (standard or urgent), CareSource 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.
Opioid drugs must meet the following prior authorization requirements:
- Less than 90 days of therapy in the last 365 days
- Less than 90 morphine milligram equivalents per day
- No concurrent therapy with benzodiazepines
- All extended release opioids require prior authorization
Most specialty pharmacy medications require prior authorization from CareSource. Access our pharmacy policies by selecting Policies from the Quick Links for more information.
You can submit specialty pharmacy prior authorization requests:
Online: Provider Portal
- 1-866-930-0019 (Pharmacy Benefit)
- 1-888-399-0271 (Medical Benefit)
Prior Authorization Forms
- Pharmacy Prior Authorization Form
- Specialty Pharmacy Prior Authorization Form
- Synagis Prior Authorization Form
- Hepatitis C Prior Authorization Form
- Medication-Assisted Treatment (Buprenorphine Products) Prior Authorization Form
- Compound Prior Authorization Form
- Hyaluronic Acid Injections Prior Authorization Form
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 or allergies to drugs or inadequate or 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 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.
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.
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.
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.
- Policies – View our most recent Home Infusion Therapy pharmacy policy.
- Home Infusion Therapy Prior Authorization Requirements, Pharmacy Criteria and Billing Guidelines network notification
- Home Infusion Therapy Per Diem Authorization Requirements
- Authorization Requirements for Medications Under the Medical Benefit – Confirm that the medication also meets plan-specific prior authorization criteria.
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 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 1-833-230-2155.
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.