Pharmacy

As a Qualified Health Plan in the Health Insurance Marketplace, CareSource provides prescription drug coverage. This benefit provides coverage for prescriptions obtained from a retail pharmacy, mail-order pharmacy or specialty pharmacy; and those that are administered by a healthcare professional in their office, in the patient’s home, or in another health care setting.

CareSource uses evidence-based guidelines to ensure health care services and medications meet the standards of excellent medical practice and are the lowest cost alternative for the member. These requirements ensure appropriate use of these medications.

Cost Share

Members may be required to pay copays for prescription drugs. Copay amounts vary based on plan and medication. Coinsurance may apply to specialty medications depending on the plan. View the Provider Manual for more information, or call us at 1-833-230-2101.

Drug Formulary

CareSource updates the formulary regularly. Visit the Drug Formulary Page for more information.

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 drug to produce the same effect and have the same safety profile as the brand name drug. If a brand name drug is requested when an equivalent generic drug is available, you may need to request prior authorization. Also, members may pay additional costs for brand name drugs when an equivalent generic drug is available.

Prior Authorization

Some drugs may require prior authorization before they will be covered. Refer to the Drug Formulary Page to determine which drugs will require prior authorization.

*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:

• Pharmacy Benefit Fax: 1-866-930-0019
• Pharmacy Benefit Phone: 1-833-230-2101

For physician administered drugs, please reference the Authorization Requirements for Medications Under the Medical Benefit. Prior authorization requests for medications covered under the outpatient Medical Benefit may be submitted online through the CareSource Provider Portal or by fax at 1-888-399-0271.

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.

Opioid drugs always require prior authorization in the following circumstances:

• More than 90 days of therapy in the last 365 days
• Less than 80 morphine milligram equivalents per day
• No concurrent therapy with benzodiazepines
• All extended-release opioids require prior authorization

Prior Authorization Forms

Pharmacy Prior Authorization forms are located on the Providers > Tools & Resources > Forms.

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-formulary, formulary 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.

Exceptions

CareSource has an exception process that allows the member or the member’s representative to request a formulary exception. Reasons for exceptions may include intolerance to drugs, allergies to drugs, or inadequate/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.

CareSource then reaches out to the provider to obtain the appropriate documentation. 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, CareSource will consider whether the requested drug is clinically appropriate.

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 makers’ recommended dosing, patient safety, applicable state and federal laws, or the Food & Drug Administration (FDA) recommendations.

Step Therapy

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 in accordance with applicable state and federal law.

Therapeutic Interchange

A member might have a drug allergy or intolerance, or a certain drug might not be effective. If a non-formulary agent is requested, the provider will need to submit a prior authorization request. This is called therapeutic interchange.

Home Infusion Therapy

For most home infusion therapy services, 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.

Resources:

• Policies – View our most recent Home Infusion Therapy pharmacy policy.
• Home Infusion Therapy Prior Authorization Requirements, Pharmacy Criteria and Billing Guidelines network notification
• Home Infusion Therapy Per Diem Authorization Requirements
• Navigate Authorization Requirements for Medications Under the Medical Benefit 

Maximum Allowable Cost (MAC)

CareSource is dedicated to providing the most current MAC pricing for drug reimbursement.

MAC pricing can be accessed through the secure ESI Provider Portal.

MAC Appeals can be completed through the portal and by following the Navigate ESI Appeals Process instructions.

Pharmaceutical Management Procedures

To learn more about how to use our pharmaceutical management procedures, look in the drug formulary. CareSource provides pharmaceutical management procedures annually and after updates. Changes are made in writing by mail, fax or email or via the web. If you have any questions regarding our pharmaceutical management procedures, please call Clinical Pharmacy Services at  1-833-230-2101.

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.