Pharmacy

HAP CareSource™ and Express Scripts® (ESI) are partnering 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), or formulary, is a list of drugs that are covered under the plan. HAP CareSource aligns with the State – PDL and Common Formulary products, which can be located for reference here. PDLs are updated regularly. Visit the Drug Formulary page for more information.

Prior Authorization

Medications administered under the pharmacy benefit may require prior authorization before they will be covered. Refer to the PDL or Formulary Search Tool to determine which drugs need prior authorization.

Medications to be administered in an outpatient setting by a physician and billed under a member’s medical benefit may also require prior authorization. Refer to the HAP CareSource Medicaid Medical Drug Review Guidelines located in the Formulary Search Tool to determine which drugs require a prior authorization.

Prior authorization requests for medications covered under the medical benefit may be submitted electronically through the HAP CareSource provider portal or by fax.

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. In emergent situations, pharmacy benefit requests may be accepted over the phone.

  • Electronic (pharmacy benefit): CoverMyMeds or SureScripts prior authorization portal
  • Fax (pharmacy benefit): 1-866-930-0019
  • Phone: 1-833-230-2102
    • Follow the prompts for Provider, then Pharmacy.
    • Phone submission should only be used for urgent pharmacy benefit requests and is not for routine prior authorization requests.

For all prior authorization decisions (standard or expedited), HAP 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.

Policies

HAP 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.

For policies related to the State-PDL and Common Formulary products, please consult state prior authorization and step therapy documents.

Exceptions

HAP 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 or Formulary. 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.

The HAP 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, HAP CareSource will consider whether the requested drug is clinically appropriate.

You must give us a written statement that explains the medical reason(s) for requesting an exception. To ensure there is no delay in the review process, be sure to include this 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.

HAP CareSource will prefer brand medications as required by the State’s PDL or Common Formulary. Outside of these requirements, 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.

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 manufacturers’ recommended dosing, patient safety, State PDL or Common Formulary approved limits or the Food & Drug Administration (FDA) recommendations.

Step Therapy

Sometimes, HAP CareSource will require a member to try one (usually less expensive) drug before the plan will pay for coverage of another (usually more expensive) drug for that same medical condition. This is called step therapy. Certain drugs may only be covered if step therapy is met.

Home Infusion Therapy

HAP CareSource requires prior authorization for home infusion therapy services for participating providers.

If you are not a participating preferred provider, you must also submit a prior authorization request before rendering home infusion therapy services.

Maximum Allowable Cost (MAC)

HAP 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.

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.

Medicaid Providers

Pharmacy Claims Processing Information

HAP CareSource has a unique set of BIN/PCN numbers for processing Medicaid pharmacy claims.

BIN: 003858
PCN: MA
RxGRP: CSHAPMI

To help you more easily identify Medicaid rebatable National Drug Codes (NDCs), please review the Navigate Medicaid Drug Rebate Program Labeler List Reference.

For additional claims processing requirements/information for HAP CareSource, please refer to the Express Scripts Pharmacy Resource site or call the Express Scripts Pharmacy Help Desk at 1-800-922-1557.