We want to make sure our members get the safest, most cost-effective drugs for their needs. We use evidence-based guidelines to make sure our formulary meets best medical practices.
Drug Formulary Changes
Effective monthly, there may be changes to our Drug Formulary. You can check the Notice of Formulary Changes to see if any of these changes affect the medicines you take.
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, associated state or federal laws, or the Food & Drug Administration (FDA) recommendations. The abbreviation “QL” is used in the Drug Formulary to show there is a quantity limit.
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 and in accordance with applicable state laws. The abbreviation “ST” is used in the Drug Formulary to show when Step Therapy is required.
Generic Substitution and Therapeutic Interchange
A pharmacy may provide a generic drug 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. This is known as therapeutic interchange.
Generic drugs usually cost less than their brand-name equivalents.
In most instances, a brand-name drug for which a generic product becomes available will become non-formulary, with the generic product covered in its place, upon release of the generic product onto the market. However, the formulary document is subject to state-specific regulations and rules regarding generic substitution and mandatory generic rules apply where appropriate.
How to Request a Medicine not on the Formulary
Sometimes a member may have a drug allergy or intolerance. Or, a certain drug may not be effective for a member. In these cases, the member or the member’s representative may ask for an exception to drugs listed on the CareSource Marketplace 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 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.
Drug Safety Recalls
Sometimes, a drug manufacturer or the federal government issues drug recalls. To find out if a drug you take is being recalled, please check the listings on the U.S. Food & Drug Administration website.