CareSource RX Innovations 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 or the list of drugs that require prior authorization 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.
Prior authorization requests may be submitted electronically (ePA) or by fax. In an emergency situation, 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, 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.)
- Directions for use (SIG) and duration of treatment requested
- Provider NPI (for both the 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.
Infusion medications included in the CareSource Site of Care program will only be allowed to be administered in a physician’s office, a freestanding infusion center or the patient’s home. Providers must submit clinical medical necessity for a patient to receive any of these medications in a hospital outpatient infusion center.
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 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 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.
Home Infusion Therapy
For most traditional home infusion therapy services, CareSource may 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 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.