CVS Caremark, a Pharmacy Benefit Management (PBM) company, administers the pharmacy program for CareSource. Working with CVS Caremark, we maintain a Preferred Drug List (PDL) and quarterly PDL updates.
Formulary or Preferred Drug List (PDL)
CareSource updates the PDL 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 will need to request prior authorization.
Some drugs may require prior authorization. Refer to the PDL to determine which drugs need prior authorization.
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.
Prior authorization requests may be submitted online, over the phone or by fax.
Online: Provider Portal
Phone: 1-855-202-1058 (Phone requests are not for routine prior authorization requests. )
You may submit requests using the following forms:
- Pharmacy Prior Authorization Form
- Immediate Release Opioid Prior Authorization Form
- Extended Release Opioid Prior Authorization Form
- Diabetes Testing Supplies Prior Authorization Form
- MAT Prior Authorization form
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
Fax (pharmacy benefit): 1-866-930-0019
Fax (medical benefit): 1-888-399-0271
Specialty pharmacy prior authorizations must include:
- Either the Universal 17P Authorization Form, the Specialty Pharmacy Prior Authorization Form, or the Synagis Prior Authorization Form
- The J-code and National Drug Code (NDC) number (Refer to the appropriate pharmacy or medical policy for the most up-to-date J-code and NDC number for the medication you are requesting.)
- Supporting clinical documentation
Claims for specialty medications must include:
- Prior authorization form
- NDC number
- Revenue code 636, if administered in the outpatient setting
Note: Codes J3490, J3590, J8499 must be billed with an NDC number in order for the claim to pay.
CareSource pharmacy and medical policies include therapy class policies that are used as a guide when determining health care coverage for our members with benefit plans covering prescription drugs. The policies are written on selected prescription drugs requiring prior authorization or step therapy. The policy is used as a tool to be interpreted in conjunction with the member’s specific benefit plan. Providers can find policies for each plan by accessing Policies from the Quick Links.
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.
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.
Typically, our PDL includes more than one drug for treating a particular condition. These different possibilities are called alternative drugs. If an alternative drug would be just as effective as the drug you are requesting and would not cause more side effects or other health problems, we generally will not approve a request for an exception.
You must give us a written statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information when you ask for the exception.
Some drugs have limits on how much can be given to a member at one time. Quantity limits are based on the approved recommended dose frequencies. Patient safety is also considered.
Members may need to try one drug before taking another. This is called step therapy. A member must try a medicine on the formulary before a non-formulary drug would be approved by CareSource. Certain drugs will be covered only if step therapy criteria is used.
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 traditional 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. Prior authorization is required if a specialty drug is administered by a home infusion facility. Check the Authorization Requirements for Medications on the Medical Benefit to determine if a prior authorization is required.
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 CVS/Caremark provider portal.
MAC Appeals can be completed through the portal and by following the CVS Caremark Appeals Process instructions.
Pharmaceutical Management Procedures
To learn more about how to use our pharmaceutical management procedures, look in the PDL. 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 1-877-362-5670.
Georgia Lock-In Program (GA LIP)
GA LIP is a health and safety program which protects members whose use of services exceeds medical necessity. Use of controlled substances is monitored, and members are assigned designated providers. GA LIP enrollees must get their medicines filled at one pharmacy and use their primary care provider for medical care.
Drug Safety Recalls
To find out if a drug you’ve prescribed to a patient is being recalled, please check the listings on the FDA website.