Pharmacy

Our three CareSource Medicare Advantage plans provide 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 in the patient’s home, including drugs administered through a home health agency.

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.

Formulary or Preferred Drug List (PDL)

CareSource updates the PDL regularly. Visit the Drug Formulary page for more information.

Restrictions & Limits

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

  • Prior Authorization: CareSource requires you to get prior authorization for certain drugs. This means that you will need to get approval from CareSource before the prescription is filled. If you don’t get approval, CareSource may not cover the drug.
    Navigate2019 Prior Authorization Criteria
    2018 Prior Authorization Criteria
  • Step Therapy: In some cases, CareSource requires you to first try certain drugs to treat a medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat the medical condition, CareSource may not cover Drug B unless you try Drug A first. If Drug A does not work for you, CareSource will then cover Drug B.
    Navigate2019 Step Therapy Criteria
    2018 Step Therapy Criteria
  • Quantity Limits: Certain drugs have limits to the amount of the drug the plan will cover. For example, the plan may provide 30 tablets per prescription for Atorvastatin 80mg. This may be in addition to a standard one month or three-month supply.

Pharmaceutical Management Materials

To learn more about how to use our pharmaceutical management procedures, look in the summary section of the 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 1-844-679-7865 from 8 a.m. to 6 p.m. Monday through Friday.

Contact Information for Coverage Decisions

Mail: CareSource Part D Appeals
c/o CVS Caremark
P.O. Box 52000 MC 109
Phoenix, AZ  85072-2000

Phone: 1-800-418-0172 (TTY: 1-800-743-3333)

We are open 8 a.m. – 8 p.m. Monday through Friday, and from Oct. 1 – March 31 we are open the same hours 7 days a week.

Fax: 1- 855-633-7673

CareSource is an HMO with a Medicare contract. Enrollment in CareSource Advantage Zero Premium™ (HMO), CareSource Advantage® (HMO), and CareSource Advantage Plus™ (HMO) depends on contract renewal. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.