Preferred Drug List
CareSource covers all medically necessary Medicaid-covered drugs at many pharmacies. CareSource also covers many commonly used over-the-counter (OTC) medications with a written prescription from your doctor.
CareSource uses Preferred Drug Lists, also called PDLs. These are drugs that we like our providers to prescribe. These lists show the most common, but not all, drugs covered by HHW and HIP plans.
Changes to the PDL are also posted every quarter.
Preferred Drug Lists
Find My Prescriptions
Do you want to look up your medicine and find out if it is covered by CareSource? It’s easy when you use our Find My Prescriptions tool. This tool will help you learn how to find your medicine.
For some drugs, we may also require that your doctor send us some information. This is called a prior authorization request. It tells us why a certain drug and/or a certain amount of drug is needed. We must approve the request before you can get the drug.
Here are some reasons a prior authorization may be needed:
- There is a generic or pharmacy alternative drug available.
- The drug could be misused/abused.
- There are other drugs that should be tried first.
- Some drugs require additional information from your provider.
CareSource will review and give a decision within 24 business hours of the original receipt of a pharmacy prior authorization request.
If it is an emergency, a 72-hour override may be used so that you can get your medicine.
Prior authorization requests for a drug may not get approved. If not approved, we will send you information on how you can appeal our decision and your right to a state hearing.
How to Request a Medicine Not on the PDL
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 a drug listed on the PDL. The member or member’s representative can call Member Services to make the request, or complete the online Member Exception Request for Non-Preferred Medication.
CareSource then contacts the appropriate health partner. CareSource may ask the health partner to provide written clinical documentation about why the member needs an exception. Health partners must provide this information.
CareSource will provide a decision no later than 72 hours after the request is received. If the member is suffering from a serious health condition, CareSource will provide a decision within 24 hours. As part of the process, CareSource will consider whether the requested drug is clinically appropriate.
Find My Prescriptions
Do you want to look up your medicine and find out if it is covered by CareSource? It’s easy when you use our Find My Prescriptions tool. This tool will help you learn how to find out if certain drugs are covered by CareSource.
A pharmacy will provide a generic drug if available in place of a brand-name drug. This is called generic substitution. Members and health care 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, a prior authorization request will need to be submitted from your provider.
Sometimes a member might have a drug allergy or intolerance, or a certain drug might not be effective and a non-preferred agent is requested. This is called therapeutic interchange. The provider will then need to submit a prior authorization request.
Sometimes, a member must try a medicine on the PDL before a drug that is not on the PDL would be approved by CareSource. This is called step therapy. Certain drugs are covered only if step therapy is used.
Some drugs have limits on how much can be given to a member at one time. Quantity limits are based on the drug makers’ recommended dosing frequencies. Patient safety is also considered.
Drug Safety Recalls
Sometimes, 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.
*NOTE: While CareSource covers all medically necessary Medicaid-covered medications, we use a Preferred Drug List (PDL). These are drugs that we prefer your provider prescribe. Typically, our PDL includes more than one drug for treating a particular condition. These different possibilities are called “alternative” drugs. Many alternative drugs are just as effective as other drugs and do not cause more side effects or other health problems.