Preferred Drug List

CareSource may need to review some drugs before they will be covered. This is called a Navigate prior authorization. Your provider will contact us and explain why you need a certain drug and/or a certain amount of a drug. We must approve the request before it will be covered. Learn more about prior Navigate authorization requirements for medications.

Here are some reasons a prior authorization may be needed:

• The drug could have dangerous side effects.
• There is a generic or preferred alternative drug available.
• The drug could be misused/abused.
• There are other drugs that should be tried first.

CareSource will review and give a decision within 24 hours of the original receipt of a pharmacy prior authorization request unless additional information is required from your doctor. In an emergency, your pharmacy may override a prior authorization requirement for 72 hours so that you can get your medicine in the meantime.

Prior authorization requests for a drug may be denied. If the request is denied, we will send you information explaining our decision, and what your options are. You can see on the PDL above which drugs require a prior authorization. You can call Member Services to ask about our PDL and which drugs or services require a prior authorization.

How to Request a Medicine Not on the PDL

You can ask us to cover a medicine that is not on our preferred drug list. This is called asking for an exception. To ask for an exception, please fill out this form. When you are done, click “Submit Request.” Our Pharmacy department will look at your request and give you an answer within 24 hours unless additional information is required from your doctor.

Generic Substitution

Therapeutic Interchange

Sometimes you can’t take a certain drug, like if you have an allergy. Other times, a drug might not work for you. In these cases, your provider can ask CareSource to cover a drug that is not on the approved drug list.

Step Therapy

Sometimes, CareSource requires that you try a less expensive medicine used for 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 used.

Quantity Limits

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 the drug makers’ recommended dosing, patient safety, or the Food & Drug Administration (FDA) recommendations.

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.