Pharmacy

Formulary or Preferred Drug List (PDL)

Humana – CareSource® maintains a Preferred Drug List (PDL) that is updated quarterly. For the most up-to-date information, access the online Formulary Search Tool located in the Quick Links or view the Preferred Drug List corresponding to your member’s plan.

Drug Formulary Changes

Each quarter, there will be changes to our PDL. You can check the Notice of Formulary Changes to see if any of these changes affect the medicines you prescribe.

Generic Substitution

A pharmacy will provide, if available, a generic drug in place of a brand-name drug. This is called generic substitution. Members and health partners 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.For more information on the criteria that needs to be met for approval of dispense as written (DAW) requests, please see our policies.  

Prior Authorization 

Prior authorization requests may be submitted via the online Provider Portal, fax, or phone. Phone requests are not for routine prior authorization requests. You may submit requests using the following forms:

Phone: 1-855-852-7005

Fax: 1-866-930-0019

OnlineUse the Provider Portal to submit prior authorization requests.

Medications billed on the medical benefit may also require prior authorization. Check the Authorization Requirements for Medications on the Medical Benefit.​ For all prior authorization decisions (standard or urgent), Humana – 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.

Exceptions

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.

Humana – CareSource has an exception process that allows the member or the member’s representative to make a request for an exception to a formulary rule or requirement. 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.

Humana – CareSource then reaches out to the provider to obtain the appropriate documentation. Humana – 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, Humana – CareSource will use many sources of information to determine whether approval for the exception will be granted.

Therapeutic Interchange

Therapeutic interchange is the practice of replacing, with the prescribing physician’s approval, a prescription medication originally prescribed for a patient with a chemically different medication. Medications used in therapeutic interchange programs are expected to produce similar levels of clinical effectiveness and sound medical outcomes, based on available scientific evidence.

Home Infusion Therapy

For most traditional home infusion therapy services, Humana – 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 NavigateAuthorization Requirements for Medications on the Medical Benefit to determine if a prior authorization is required.

Maximum Allowable Cost (MAC)

Humana – 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 following the CVS Caremark® Appeals Process instructions.

Kentucky Lock-In Program

KLIP is a program for Kentucky Medicaid members who need help managing their health care needs. It is intended to limit overuse of benefits and reduce unnecessary costs to Medicaid while providing an appropriate level of care for the member.