Pharmacy

Before providing care or prescribing medicine for your patients, please review the CareSource MyCare Ohio (Medicare-Medicaid Plan) Preferred Drug List and the Preferred Drug List Changes. 

To make your search easy, use the Formulary Search Tool to look up covered drugs and criteria.

Formulary or Preferred Drug List (PDL)

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

Copayments

Members who have CareSource MyCare Ohio coverage for both Medicare and Medicaid have no copays for covered prescription and over-the-counter (OTC) drugs.

Members who have CareSource MyCare Ohio coverage for Medicaid only may have copays for Medicare Part D drugs that are received through their Medicare health care plan. Members can contact their Medicare plan to determine if they have Medicare Part D drug copays. For non-Part D prescription drugs, these members will not have any copays.

Formulary Exceptions

During the course of a member’s medical care, there may be instances when a member requires a non-formulary drug or a drug that has formulary limits or restrictions (e.g., step therapy requirements, prior authorization or quantity limits):

If a medication requires step therapy or prior authorization, use the Navigate Request for Medicare Prescription Drug Coverage Determination form. This form can also be completed and submitted online. 

CareSource MyCare Ohio may approve an exception request for a non-formulary drug or a drug that has formulary limits or restrictions when medically necessary. To determine medical necessity, CareSource MyCare Ohio will verify, through the provider’s supporting statement(s) and/or standards documented in clinical guidelines adopted by CareSource MyCare Ohio, that:

  • The member has tried and failed and/or has documented contradictions or intolerance to the equivalent formulary medications, and
  • No other formulary agent is appropriate to treat the member’s condition.

Exception requests will be processed through CareSource MyCare Ohio’s Pharmacy Benefit Manager (PBM) prior authorization review process.

Tiered Medications

Medications are classified using the following tier levels:

  • Tier 1: Medicare Part D Generic Drugs
  • Tier 2: Medicare Part D Preferred Brand Drugs
  • Tier 3: Non-Medicare Covered Prescription & OTC Drugs

Tiered Cost Sharing Exceptions

A member must meet appropriate medical necessity criteria before tiered cost sharing exceptions will be approved. To determine medical necessity, the CareSource MyCare Ohio PBM will verify, through the provider’s supporting statement(s) and/or standards documented in clinical guidelines adopted by the plan, that all drugs in the lower preferred tiers:

  • Would not be as effective for the member as the requested drug,
  • Would have adverse effects for the member, or
  • Both criteria above are met.

Tiered cost sharing exception requests will be processed through CareSource MyCare Ohio’s PBM prior authorization review process.

Prior Authorization Review Process

CareSource MyCare Ohio will process coverage determinations and exception requests in accordance with Medicare Part D regulations. Requests will be handled through the prior authorization review process. Prior authorization requires a drug to be “pre-approved” in order for it to be covered under a benefit plan.

The prior authorization staff will adhere to the CareSource MyCare Ohio Centers for Medicare & Medicaid Services (CMS) approved criteria. The PBM’s National Pharmacy and Therapeutics Committee establishes clinical guidelines and other professionally recognized standards to review each case, rendering a decision based on established protocols and guidelines.

Providers can submit requests by any of the methods identified below. Providers are required to submit pertinent medical/drug history, prior treatment history and any other necessary supporting clinical information with the request. Standard requests will be reviewed and determinations will be made within 72 hours.

Expedited or urgent requests will be reviewed and determinations will be made in 24 hours. A request is considered urgent if the requester believes that applying the standard process may seriously jeopardize the member’s life, health or ability to regain maximum function. Providers will be notified by phone or fax of the determination.

Prescribers or their designated agents may request authorization by one of the following mechanisms:

  • Online submission
  • Navigate Form for office use
  • Written request via fax: 1-877-328-9660 for oral medications and injectable/specialty medications
  • Toll-free phone number: 1-800-488-0134

For more information, please call Provider Services at 1-800-488-0134.