Pharmacy

As a Qualified Health Plan in the Health Insurance Marketplace, CareSource provides prescription drug coverage. This benefit provides coverage for prescriptions obtained from a retail pharmacy, mail-order pharmacy or specialty pharmacy; and 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. These requirements ensure appropriate use of these medications.

Copayments

Members may be required to pay cost-share for prescription drugs. Cost-share amounts vary based on plan and medication. View the Navigate Provider Manual for more information, or call us at 1-833-230-2101.

Drug Formulary

CareSource updates the formulary regularly. Visit the Drug Formulary page for more information.

Generic or Biosimilar Substitution

A pharmacy will provide a generic or interchangeable biosimilar drug if available in place of a brand name drug or reference biologic. Members and providers can expect the generic or biosimilar drug to produce the same effect and have the same safety profile as the brand name drug or reference biologic. If a brand name drug or reference biologic is requested when an equivalent generic or biosimilar drug is available, you may need to request a prior authorization. Also, members may pay additional costs for brand name drugs or reference biologics when an equivalent generic or biosimilar is available.

For more information about generic substitution, please refer to the FDA Orange Book. For more information about biosimilar substitution, please refer to the FDA Purple Book.

Prior Authorization, Step Therapy and Quantity Limits

Utilization management may be applied to Formulary drugs administered under the pharmacy benefit when they are included on the formulary. This could include:

  • Prior authorization – Requirement for additional clinical documentation prior to coverage of the requested drug
  • Step therapy – Requirement to try an alternate drug before the requested drug
  • Quantity limit – Limit on how much of a drug can be dispensed at a time or over a period of time

Refer to the Drug Formulary or Formulary Search Tool to determine which Formulary drugs are subject to these restrictions.

Note: Opioid drugs will always require prior authorization in the following circumstances:

  • The member has already had at least 90 days of therapy in the last 365 days,
  • The prescription is for more than 80 morphine milligram equivalents per day,
  • The member is receiving concurrent therapy with benzodiazepines, and/or
  • The prescription is for an extended-release opioid.

Drugs administered in the outpatient setting by a physician and billed under a member’s medical benefit may also require prior authorization. Refer to the Authorization Requirements for Medications Under the Medical Benefit to determine which drugs require a prior authorization.

Prior authorization requests, including requests for exception to a step therapy or quantity limit restriction, for pharmacy benefit administered drugs can be submitted three ways:

  • Electronically via the SureScripts or CoverMyMeds Portals (preferred)
  • Pharmacy benefit fax: 1-866-930-0019
  • Phone: 1-833-230-2101

This includes prior authorization requests for both traditional and specialty medications and requests for exception to a step therapy or quantity limit restriction.

Prior authorization requests for physician administered drugs (billed under the medical benefit) can be submitted electronically via the CareSource Provider Portal (see Providers then Prior Authorization and Notifications then Physician Administered Pharmacy Codes). They can also be submitted by fax: 1-888-399-0271.

Note: All oncology medication treatment regimen requests must be submitted and reviewed through the EVITI Connect Portal.

For all prior authorization decisions (standard or expedited), CareSource provides notice to the provider and member as expeditiously as the member’s health condition requires. Please specify if you believe the request is urgent.

Prior Authorization Forms

Policies and Criteria

CareSource uses pharmacy policies or criteria when determining coverage of prescription drugs. Policies or criteria apply to coverage reviews for non-formulary drugs and drugs that are included on the formulary with a prior authorization or step therapy requirement. These policies and criteria are a tool to be interpreted in conjunction with the member’s specific benefit plan and the Drug Formulary. Access pharmacy policies by selecting Policies from the Quick Links. Traditional drug review criteria can be viewed in the online Formulary Search Tool.

Non-Formulary Drugs and Therapeutic Interchange

CareSource has an exception process that allows the member or the member’s representative to make a request for a formulary exception. Reasons for the exception may include an intolerance to Formulary drugs, allergies to formulary drugs, and/or inadequate or inappropriate response to Formulary drugs. The member or member’s representative can call Member Services to make the request or can complete the online Member Exception Request for Non-Formulary Medication.

When a non-formulary drug is requested due to drug allergy or intolerance or lack of efficacy of a formulary drug, the prescriber will need to submit supporting clinical documentation just like when requesting a prior authorization. Request for a non-formulary alternative is also called therapeutic interchange.

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 drug makers’ recommended dosing, patient safety, applicable state and federal laws, or the Food & Drug Administration (FDA) recommendations.

Step Therapy

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 in accordance with applicable state and federal law. 

Therapeutic Interchange

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

Home Infusion Therapy

CareSource offers home infusion services to members who require treatment with certain injectable drugs. These services allow members to schedule and receive therapy safely and effectively in the comfort of their own home at a time that works best for their schedule. An infusion-trained nurse will administer the drug and remain with the member during the entire infusion. In most cases, home infusion services will be a lower cost to members through their plan benefits. Members can contact member services for more information about transitioning to home infusion therapy.

Maximum Allowable Cost (MAC)

CareSource is dedicated to providing the most current MAC pricing for drug reimbursement.

MAC pricing can be accessed through the secure ESI Provider Portal. 

MAC Appeals can be completed through the portal and by following the Navigate ESI Appeals Process instructions.

Pharmaceutical Management Procedures

To learn more about how to use our pharmaceutical management procedures, look in the drug formulary. 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 1-833-230-2101.

Drug Safety Recalls

Sometimes, a drug manufacturer or the federal government issues drug recalls. To find out if a drug you have prescribed to a patient is being recalled, please check the listings on the FDA website.