Prescription Drug Formulary

Your Prescription Drug Formulary (or just Formulary) is a list of cost-effective drugs that you might use. Usually, drugs and devices on the Formulary are covered for you, but sometimes limits apply. You can find more information about these limits below. Sometimes, you may need a drug that is not on the Formulary. You can find more information below about requesting a drug that is not on the Formulary.

We want to make sure our members get the safest, most cost-effective drugs for their needs. Refer to your Evidence of Coverage (EOC) for more information about how drugs are included or not included on your Formulary.

Drug Formulary Changes

We review your Formulary regularly and may make changes. You can check the Notice of Formulary Changes to see if any of these changes affect the medicines you take. If we make a negative change to your Formulary that impacts a drug you are taking, we will send you a notice before the change takes effect. A negative change is one where the cost goes up or we ask for quantity limits or step therapy. 

Your provider can request an exception to the change within 60 days of receiving the notice.

Prescription Costs

  • Using our Price a Medication tool is a quick way to confirm your prescriptions costs. Drugs on the CareSource formulary are placed in 5 different levels or tiers. Each tier has a different cost-sharing amount. because of frequent changes in the price of medications, the prescription costs in the Price A Medication tool may not be exact.
  • Some out-of-state pharmacies do not take CareSource, but most chain drug stores across the country do. If you think you will travel out of our service area, be sure to fill your prescriptions before you leave. You can also use our Find A Pharmacy tool to confirm if there is a pharmacy in your area.

Quantity Limits

On your Formulary, Quantity Limits show as “QL.” This usually limits how much of a drug you can get over a certain time period, like a month or a year. We put a Quantity Limit on a drug to make sure it is being used at doses that the Federal Food and Drug Administration (FDA) has approved. Quantity Limits also ensure your prescriptions cost as little as possible for both you and your plan.

Step Therapy

On your Formulary, Step Therapy limits show as “ST.” If a drug has a Step Therapy limit, you will need to try another drug first if the drug costs less and works just as well for most people. You and your Provider may decide that the less costly drug is not a good fit for you. Your provider can ask to bypass the limit by sending a request electronically or by faxing it to us.

Prior Authorization

On your Formulary, Prior Authorization limits will show as “PA.” If a drug has a Prior Authorization limit, we need more information before the drug will be covered for you. Your provider will need to give us this information electronically or fax it to us. The forms they may need are on the Provider Forms page of our website.

The information we need might be about your medical history, drugs you have tried before, or certain tests your Provider may have ordered for you. We ask for this information to ensure that the drug is Medically Necessary for you.

Generic Substitution and Therapeutic Interchange

Generic drugs are as safe and effective as the brand name drug, according to the Federal Food and Drug Administration (FDA). Not all brand name drugs have a generic version available. Your pharmacy may dispense a generic drug (if it exists) instead of a brand name drug unless your provider gives them other directions on your prescription.

Generic drugs are usually in a lower tier on your Formulary and are less costly than the brand name drug.

Brand name drugs will usually be removed from your Formulary when a generic becomes available, and the generic will be added instead. If you or your provider believe that you need a brand name drug when a generic is available, you provider will need to submit more information to CareSource. We follow all state-specific regulations and rules about generic substitution.

How to Request a Medicine not on the Formulary

Sometimes you may need a drug that is not on the Formulary. You or your representative (including your Provider) can ask for an exception to the formulary. If the exception is approved, the drug will be covered. Your deductible and copayment/coinsurance will still apply, depending on your plan. You or your representative can call Member Services to make the request, or complete the online Member Exception Request for Non-Formulary Medication

If needed, CareSource will reach out to your Provider to get all the information needed. We 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.