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Indiana
Indiana

Pharmacy

Formularies

CareSource® maintains the following formularies (preferred drug lists) and quarterly updates:

NavigateFormulary Search Tools

Our online drug formularies can help you quickly look up medications for CareSource members. It’s easy! You can find out if a medication is covered by searching alphabetically, by brand and generic name or by therapeutic class:

The following apps can be downloaded on your Android or Apple device:

  • MMIT Formulary
  • Epocrates
  • Fingertip Formulary 

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 health partners can expect the generic to produce the same effect and have the same safety profile as the brand-name drug. If a brand-name product is requested when a generic equivalent is available, the health partner will need to submit a request for prior authorization.

Prior Authorization

Some drugs on the formulary require prior authorization. Refer to the appropriate formulary, formulary search tool or NavigateDrugs that Require Prior Authorization list to determine what drugs need prior authorization. 

NavigatePrior authorization requests may be submitted over the phone, fax or web.

Phone: 1-844-607-2831

Fax: 1-866-930-0019

Online: Use the Provider Portal to submit prior authorization requests

Medications billed on the medical benefit may also require prior authorization. Please check the NavigateAuthorization Requirements for Medications on the Medical Benefit.​ For all prior authorization decisions (standard or urgent), CareSource provides notice to the health partner and member as expeditiously as the member’s health condition requires. Please specify if you believe the request is urgent.

Specialty Pharmacy

Most specialty pharmacy medications require prior authorization from CareSource. You can submit prior authorization requests for these medications by phone or fax:

  • Phone: 1-844-607-2831
  • Fax (pharmacy benefit): 1-866-930-0019
  • Fax (medical benefit): 1-888-399-0271

Specialty pharmacy prior authorizations must include:

Claims for specialty medications must include:

  • Prior authorization form
  • J-code
  • NDC number
  • Revenue code 636, if administered in the outpatient setting

Note: Codes J3490, J3590 and J8499 must be billed with an NDC number in order for the claim to pay.

Pharmacy Policies

Our pharmacy policies include therapy class policies that are used as a guide when determining health care coverage for our members with benefit plans covering prescription drugs. Policies are written on selected prescription drugs requiring prior authorization or step therapy. The policy is used as a tool to be interpreted in conjunction with the member's specific benefit plan. You can access medical, pharmacy, reimbursement and administrative policies from our Policies webpage. 

Exceptions

CareSource has an exception process that allows the member or the member's representative to make a request for an exception. Reasons for exceptions may include intolerance or allergies to drugs or inadequate or inappropriate response to drugs listed on the drug 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 health partner 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. Health partners 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 at one time. Quantity limits are based on the approved recommended dose frequencies. Patient safety is also considered.

Step Therapy

Members may need to try one drug before taking another. This is called step therapy. A member must try a medicine on the formulary before a non-formulary drug would be approved by CareSource. Certain drugs will be covered only if step therapy criteria is used.

Therapeutic Interchange

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

Management Procedures

To learn more about how to use our pharmaceutical management procedures, look in the summary section of the PDL. 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 1-877-362-5670