Drug Management Program

CareSource has a program that can help make sure our members safely use their prescription opioid medications, or other medications with a high potential for abuse. This program is called a Drug Management Program (DMP). If a member uses opioid or benzodiazepine medications that they get from several doctors or pharmacies, we may talk to their doctors to make sure their use is appropriate and medically necessary. Working with the doctors, we decide the member is at risk for misusing or abusing opioid or benzodiazepine medications, and limit how they can get those medications. The limitations may be:

• Requiring the member to get all their prescriptions for opioid or benzodiazepine medications from one pharmacy
• Requiring the member to get all their prescriptions for opioid or benzodiazepine medications from one doctor
• Limiting the amount of opioid or benzodiazepine medications we will cover for the member

If we decide that one or more of these limitations should apply to a member, we will send them a letter in advance. The letter will have information explaining the terms of the limitations we think should apply. The member will have an opportunity to tell us which doctors or pharmacies they prefer to use. If the member thinks we made a mistake or disagrees with our determination that they are at-risk for prescription drug abuse or the limitation, the member and their prescriber have the right to ask us for an appeal. Refer to the plan’s Evidence of Coverage (Chapter 9) for information about how to ask for an appeal.

The DMP may not apply to members that have certain medical conditions, such as cancer, receiving hospice, palliative, or end-of-life care, or live in a long-term care facility.