Pharmacy

CareSource RxInnovations™ and Express Scripts® (ESI) partner to administer the pharmacy program. Working with ESI as our Pharmacy Innovation Partner, we maintain a Preferred Drug List (PDL) and PDL updates.

Preferred Drug List (PDL)

Effective July 5, 2023, CareSource will be aligning with Indiana Medicaid’s Statewide Uniform Preferred Drug List (SUPDL). We will maintain the same preferred and non-preferred drug status, clinical criteria requirements, and format for prior authorization (PA) submissions for products on the SUPDL.

The SUPDL and related criteria can be found on the IHCP Pharmacy Services page. Select “Preferred Drug List” from the Preferred Products dropdown menu to launch the SUPDL. PA Criteria links can be found with the associated Drug Class within this document. Note: CareSource PA Forms are available on the Forms page under Pharmacy Prior Authorizations.

CareSource will continue to maintain and post a Preferred Drug List (PDL). It will include SUPDL preferred products, in addition to preferred products in categories outside of the SUPDL. CareSource updates the PDL regularly. Visit the Drug Formulary page for more information.

Prior Authorization

Some drugs may require prior authorization before they will be covered. Refer to the PDL to determine which drugs need prior authorization.

Physician administered drugs billed under a member’s medical benefit may also require prior authorization.

For all prior authorization decisions (standard or urgent), CareSource provides notice to the physician and member as expeditiously as the member’s health condition requires. Please specify if you believe the request is urgent and include all necessary clinical documentation to support expeditious review.

Medical Benefit Fax: 888-399-0271

Prior authorization requests for physician administered drugs 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 on one of our Pharmacy Prior Authorization forms. They are available on the Forms page under the Pharmacy Prior Authorizations.

Specialty Pharmacy

Many specialty pharmacy medications require a prior authorization before they will be covered. Please refer to Indiana Medicaid’s criteria located on the IHCP Pharmacy Services page for SUPDL products, CareSource’s Drug Formulary page, or CareSource’s Pharmacy policies page for non-SUPDL products 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 (for drugs prescribed under the pharmacy benefit): 1-866-930-0019

Fax (for physician administered drugs under the medical benefit): 1-888-399-0271

Phone: 1-844-607-2831

Specialty pharmacy prior authorizations must include:

  • The applicable Pharmacy Prior Authorization Form
  • The drug name, strength, Healthcare Common Procedure Coding System (HCPCS) or J-code, and National Drug Code (NDC) number (Refer to the Policies page for the most up-to-date guidance on criteria for submission and review of specialty prior authorization requests)
  • 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
  • J-code
  • NDC number
  • Revenue code 636, if administered in the outpatient setting
  • Use the Navigate Change in Facility Request to request a change in facility when there is a prior authorization on file

Note: Codes J3490, J3590, and J8499 must be billed with an NDC number for the claim to pay.

Policies

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.

For policies related to products on the SUPDL, please consult Indiana Medicaid’s criteria documents located on the IHCP Pharmacy Services page. Select “Preferred Drug List” from the Preferred Products dropdown menu to launch the SUPDL. PA Criteria links can be found with the associated Drug Class within this document. Note: CareSource PA Forms are available on the Forms page under Pharmacy Prior Authorizations.

Exceptions

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 PDL.

An exception can be requested by the prescriber via fax or an electronic submission portal such as CoverMyMeds or SureScripts. Phone submissions may also be accepted if the member is suffering from a serious condition that requires urgent treatment. Members or the member’s representative may submit a formulary exception via an online form – Member Exception Request for Non-Formulary Medication or by contacting CareSource Member Services by phone.

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 and medically necessary.

You must provide the medical reason(s) for requesting an exception. To ensure there is no delay in the review process, be sure to include this information when you ask for the exception.

Generic Substitution

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.

CareSource will prefer brand medications required by Indiana Medicaid’s SUPDL. Outside of these requirements, 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.

Quantity Limits

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 manufacturers’ recommended dosing, patient safety, the Indiana Medicaid Drug Utilization Review (DUR) Board approved limits, or the Food & Drug Administration (FDA) recommendations.

Step Therapy

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 be covered only after step therapy is met. Please refer to the Drug Formulary page for more information.

Home Infusion Therapy

CareSource requires PA for home infusion therapy services for participating providers.

If you are not a participating preferred provider, you must also submit a PA request before rendering home infusion therapy services.

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.