CareSource RxInnovations™ and Express Scripts® (ESI) are partnering to administer the pharmacy program. Working with ESI as our Pharmacy Innovation Partner, we maintain a Preferred Drug List (PDL) and quarterly PDL updates.
Formulary or Preferred Drug List (PDL)
The Preferred Drug List (PDL), also known as a formulary, is a list of drugs that are covered under the plan. CareSource updates the PDL regularly. Visit the Drug Formulary page for more information.
Some drugs may require prior authorization before they will be covered. Refer to the PDL to determine which drugs need prior authorization.
Medications billed under a member’s medical benefit may also require prior authorization. Refer to 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.
Medical Benefit Fax: 888-399-0271
Prior authorization requests for medications covered under outpatient Medical Benefit for Medicaid may be submitted electronically through the CareSource Portal (ePA) or by fax.
Pharmacy Benefit Fax: 866-930-0019
Prior Authorization requests for medications covered under the Pharmacy Benefit may be submitted electronically via the CoverMyMeds or SureScripts prior authorization portals or by fax. In emergent situations, requests may be accepted via phone.
Phone: 1-844-607-2831 (Phone requests are not for routine prior authorization requests.)
You may submit requests using the following forms:
- Pharmacy Prior Authorization Form
- Medication-Assisted Treatment (Buprenorphine Products) Prior Authorization Form
- Immediate Release Opioid Prior Authorization Form
- Extended Release Opioid Prior Authorization Form
- Diabetes Testing Supplies Prior Authorization Form
- Concurrent Benzodiazepine and Opioid Prior Authorization Form
Most specialty pharmacy medications require a prior authorization before they will be covered. Refer to the PDL and pharmacy policies by selecting Policies from the Quick Links for more information.
You can submit specialty pharmacy prior authorization requests online or via fax (phone requests cannot be accepted under most circumstances for specialty medications):
Online: Provider Portal
Fax (pharmacy benefit): 1-866-930-0019
Fax (medical benefit): 1-888-399-0271
Specialty pharmacy prior authorizations must include:
- The applicable Prior Authorization form
- The drug name, strength, 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.)
- Diagnosis or ICD-10
- Dosage form, quantity, and frequency, directions for use (SIG), route of administration, and dates of service (treatment duration)
- Place of service
- Provider name, address, phone, fax, NPI, tax ID, and contact name (for both ordering and rendering providers)
- 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 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-preferred, preferred 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 prescriber, member, or the member’s representative to request coverage of a drug that is not on the preferred drug list (PDL). Reasons for exceptions may include intolerance, allergies, or contraindications to drugs listed on the formulary.
An exception can be requested via fax or an electronic submission portal such as CoverMyMeds. Phone submissions may also be accepted if the member is suffering from a serious condition that requires urgent treatment. Members may also submit a formulary exception via phone, fax, or an online form – Member Exception Request for Non-Formulary Medication.
The CareSource Pharmacy Department will review all exception requests and provide a decision no later than 24 hours after the request is received. 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.
You must give us a written statement that explains the medical reasons for requesting an exception. To ensure there is no delay in the review process, be sure to include this medical information when you ask for the exception.
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 a prior authorization and explain why the member cannot use the generic substitution.
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, or the Food & Drug Administration (FDA) recommendations.
Sometimes, CareSource will require a member to first try one (usually less-expensive) drug before the plan will pay for coverage of another (usually more expensive) drug for that same medical condition. This is called step therapy. Certain drugs may only be covered if step therapy is met.
Home Infusion Therapy
CareSource requires prior authorizations for home infusion therapy services for participating providers.
If you are not a participating preferred provider, you must also 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 Maximum Allowable Cost (MAC) pricing for drug reimbursement.
MAC pricing can be accessed through the secure Express Scripts Provider Portal.
MAC Appeals can be completed through the portal and by following the Express Scripts Appeals Process (if applicable) instructions.
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.