Pharmacy
The CareSource® Dual Advantage™ (HMO SNP) Formulary (Drug List) updates each month. This benefit provides coverage for prescriptions obtained from a retail pharmacy, mail-order pharmacy or specialty pharmacy, as well as those that are administered in the patient’s home, including drugs administered through a home health agency.
CareSource uses evidence-based guidelines to ensure health care services and medications meet the standards of excellent medical practice and are the lowest cost alternative for the member.
Restrictions & Limits
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
- Prior Authorization
- Step Therapy
- Quantity Limits
| Resources | ||
|---|---|---|
Access updates to our Formulary List. | 2024 Prior Authorization Criteria CareSource requires you to get prior authorization for certain drugs. This means that you will need to get approval from CareSource before the prescription is filled. If you don’t get approval, CareSource may not cover the drug. | In some cases, CareSource requires you to first try certain drugs to treat a medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat the medical condition, CareSource may not cover Drug B unless you try Drug A first. If Drug A does not work for you, CareSource will then cover Drug B. |
Pharmaceutical Management Materials
To learn more about how to use our pharmaceutical management procedures, look in the summary section of the formulary. CareSource provides pharmaceutical management procedures annually and after updates. Changes are made in writing by mail, fax or email or via the web.
Contact Information for Coverage Decisions
Mail: Express Scripts
P.O. Box 66571
St. Louis, MO 63166-6571
Attn: Medicare Reviews
Phone: 1-800-935-6103
Hours of operation are 24 hours a day, seven days a week, 365 days a year.
Fax: 1-877-251-5896