Pharmacy Policies

These pharmacy policies apply to provider administered drugs for our Ohio Medicaid plan, which are reimbursable by CareSource.

Claims for the drugs below are reimbursable by CareSource pursuant to Ohio Administrative Code (OAC) 5160-26-13. If the servicing (billing) provider is registered with the Ohio Department of Medicaid as a pharmacy, all pharmaceuticals must be approved and billed to the Single Pharmacy Benefit Manager, Gainwell Technologies. Claims for pharmaceuticals billed by a pharmacy to CareSource will be denied.

The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.

Current Pharmacy Policies

The following medications are managed under the Medical Benefit at CareSource. For medications payable through Gainwell Technologies, the Single Pharmacy Benefit Manager, please visit https://spbm.medicaid.ohio.gov/ or https://pharmacy.medicaid.ohio.gov/unified-pdl.

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Cell and Gene Therapy Outcomes Tracking Program

CareSource Ohio Medicaid partners with Audaire Health to capture and assess clinical benefits of Cell and Gene therapies. For more information, please refer to the Navigate CareSource Audaire Health™ Cell and Gene Therapy (CGT) Outcomes Tracking Program – Frequently Asked Questions for Providers. You can also find information about the program on our Updates & Announcements page.

Ohio Department of Medicaid Unified Preferred Drug List

The following medications are managed under the Pharmacy Benefit, or Pharmacy and Medical Benefit both, at CareSource and are found within the Ohio Department of Medicaid’s current Unified Preferred Drug List. Therefore, these medications utilize criteria outlined within the Ohio Unified Preferred Drug List. Prescribers can access the UPDL documents online through ODM’s website by viewing the UPDL and UPDL criteria.

Archived Pharmacy Policies