Pharmacy
CareSource RxInnovations™ and Express Scripts® (ESI) partner to administer the pharmacy program. Working with ESI as our Pharmacy Innovation Partner, we maintain a Preferred Drug List (PDL) and quarterly PDL updates.
Formulary or Preferred Drug List (PDL)
The Preferred Drug List (PDL) is a list of drugs that are preferred under the plan. CareSource updates the PDL quarterly. Visit the Drug Formulary page for more information.
Prior Authorization
Medications covered under the pharmacy benefit may require prior authorization before they will be covered. Refer to the PDL to determine which drugs need prior authorization.
Medications billed under a member’s medical benefit may also require prior authorization. Refer to the Authorization Requirements for Medications Under the Medical Benefit or the Procedure Code Lookup Tool.
Criteria considered during a prior authorization review can be located by searching for the requested medication in the Formulary Search Tool or in Pharmacy Policies. Select Policies from the Quick Links for more information.
Prior Authorization Submission
Prior authorization requests for medications covered under outpatient medical benefit for Medicaid may be submitted electronically through the CareSource Portal or by fax.
Medical Benefit Fax: 888-399-0271
Prior Authorization requests for medications covered under the pharmacy benefit may be submitted electronically via the CoverMyMeds or SureScripts prior authorization portals or by fax.
Pharmacy Benefit Fax: 866-930-0019
You may submit requests via fax with materials linked on the Forms page.
In emergent situations, requests may be accepted via phone.
Phone: 1-855-202-1058 (Phone requests are not for routine prior authorization requests.)
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.
Exceptions
CareSource has an exception process that allows the prescriber, member, or the member’s representative to request coverage of a drug that is not on the PDL. Reasons for exceptions may include intolerance, allergies, or contraindications to the drugs listed.
An exception can be requested via fax or through an electronic submission portal such as CoverMyMeds or SureScripts. Phone submissions may also be accepted if the member is suffering from a serious condition that requires urgent treatment. Members may also submit a formulary exception via phone, fax or an online form – Member Exception Request for Non-Formulary Medication.
The CareSource pharmacy department will review all exception requests and provide a decision as expeditiously as the member’s health condition requires. 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.
You must give us a written statement that explains the medical reasons for requesting an exception. To ensure there is no delay in the review process, be sure to include this medical information when you ask for the exception.
Policies
CareSource pharmacy policies include drug-specific and therapy class policies to be used as a guide when determining health care coverage for our members with benefit plans covering prescription drugs.
The policies are written for those prescription drugs that are non-preferred, preferred with prior authorization or require step therapy. The policy is a tool to be interpreted in conjunction with the member’s specific benefit plan. Access pharmacy policies by selecting Policies from the Quick Links for more information.
Exceptions
CareSource has an exception process that allows the prescriber, member, or the member’s representative to request coverage of a drug that is not on the PDL. Reasons for exceptions may include intolerance, allergies, or contraindications to drugs listed on the formulary.
An exception can be requested via fax or an electronic submission portal such as CoverMyMeds. Phone submissions may also be accepted if the member is suffering from a serious condition that requires urgent treatment. Members may also submit a formulary exception via phone, fax or an online form – Member Exception Request for Non-Formulary Medication.
The CareSource Pharmacy Department will review all exception requests and provide a decision within 24 hours after the request is received. 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.
You must give us a written statement that explains the medical reasons for requesting an exception. To ensure there is no delay in the review process, be sure to include this medical information when you ask for the exception.
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 providers 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, you will need to request a prior authorization and explain why the member cannot use the generic substitution.
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, 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.
Home Infusion Therapy
For most traditional home infusion therapy services, CareSource may not require participating preferred providers to submit prior authorization requests.
If you are not a participating preferred provider, you must submit a prior authorization request before rendering home infusion therapy services. Prior authorization is required if a specialty drug is administered by a home infusion facility. Check the Authorization Requirements for Medications on the Medical Benefit to determine if a prior authorization is required.
Maximum Allowable Cost (MAC)
CareSource is dedicated to providing the most current Maximum Allowable Cost (MAC) pricing for drug reimbursement.
MAC pricing can be accessed through the secure Express Scripts Provider Portal.
MAC Appeals can be completed through the portal and by following the Express Scripts Appeals Process (if applicable) instructions.
Georgia Lock-In Program (GA LIP)
GA LIP is a health and safety program which protects members whose use of services exceeds medical necessity. Use of controlled substances are monitored and members are assigned designated providers. GA LIP enrollees must get their medicines filled at one pharmacy.
If you would like to refer someone to be considered for the GA LIP, please click here and provide the following information:
- Member’s name
- Member’s date of birth
- Member’s CareSource ID number
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.