Preferred Drug List
CareSource covers all medically necessary Medicaid-covered drugs at many pharmacies. We also cover many commonly used over-the-counter (OTC) drugs with a written prescription from your doctor. While we cover all medically necessary Medicaid-covered medications, we use a Preferred Drug List (PDL). These are drugs we prefer your provider to 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.
Beginning January 1, 2020, CareSource adopted Ohio Medicaid’s Unified Preferred Drug List (UPDL). This means that CareSource will prefer the same prescription medications as all other Medicaid managed care plans in the state of Ohio.
We also have a List of Covered Vaccines to help you determine if a vaccine is covered at your provider’s office or your local participating pharmacy, and if there are any requirements for coverage. If CareSource makes any changes to the PDL, the changes are posted every quarter. Questions about Ohio’s UPDL can be directed to Member Services. You can also contact your care manager, if you have one assigned to you.
Preferred Drug List
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.
Prior authorization is how we decide if certain health services or drugs will be covered by your CareSource plan. Generally, your doctor will send us information explaining why you need a certain medication and/or a certain amount of drug. We must approve the request before we will cover the drug. Learn about authorization requirement for medications here.
Here are some reasons a prior authorization may be needed:
- The drug could have dangerous side effects.
- There is a generic or preferred alternative drug available.
- The drug could be misused/abused.
- There are other drugs that should be tried first.
CareSource will review and make a decision within 24 hours of the original receipt of a pharmacy prior authorization request unless additional information is required from your doctor. In an emergency, your pharmacy may request to override a prior authorization requirement for 72 hours so that you can get your medicine.
Prior authorization requests for a drug may be denied. If the request is denied, we will send you information explaining our decision, and what your options are. You can see on the Preferred Drug List (PDL) which drugs require a prior authorization. You can also call Member Services to ask about our PDL, and which drugs or services require a prior authorization.
How to Request a Medicine Not on the PDL
You can ask us to cover a medicine that is not on our preferred drug list. This is called asking for an exception. To ask for an exception, please fill out this form. When you are done, click “Submit Request.” Our Pharmacy department will look at your request and give you an answer within 24 hours unless additional information is required from your doctor.
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 substitution 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 you might have a drug allergy or intolerance, or a certain drug might not be effective. Your health care provider may request a drug that is not on the PDL. This is called therapeutic interchange. Your provider will then need to submit a prior authorization request.
Sometimes, CareSource requires that you try a less expensive medicine used for 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 used.
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 the drug makers’ recommended dosing, patient safety, or the Food & Drug Administration (FDA) recommendations.
Drug Safety Recalls
Sometimes, a drug manufacturer or 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.
Member Services: 1-800-488-0134 (TTY: 1-800-750-0750 or 711), Monday – Friday 7 a.m. – 7 p.m.