Pharmacy

As a Qualified Health Plan in the Health Insurance Marketplace, CareSource North Carolina Co.® 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 North Carolina Co. 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.

Cost Share

Members may be required to pay cost share for prescription drugs. Cost share amounts vary based on plan and medication. Preventive drugs are covered at no member cost share. View the Provider Manual for more information, or call us at 1-833-230-2101.

Drug Formulary

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

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 may need to request prior authorization. Also, members may pay additional costs for brand name drugs when a generic equivalent is available.

Prior Authorization

Some drugs may require prior authorization before they will be covered.

For all prior authorization decisions (standard or urgent), CareSource North Carolina Co. 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.

How We Determine What is Covered

Outpatient Drugs Covered under the Pharmacy Benefit  

Refer to the Drug Formulary and CareSource North Carolina Co. Policies to determine which drugs need prior authorization.

Outpatient Drugs Covered under the Medical Benefit  

Refer to the Procedure Lookup Tool to determine which drugs need prior authorization.

How to Submit an Outpatient Medication Prior Authorization

Outpatient Pharmacy Benefit

  • ePA – Utilize CoverMyMeds or SureScripts prior authorization portals.
  • Pharmacy Benefit Fax – 1-866-930-0019
  • Emergency situations – Requests may be accepted by phone in emergency situations. Providers should contact 1-833-230-2101 and follow the prompts from Pharmacy.

Outpatient Drugs Covered under the Medical Benefit

Specialty Pharmacy

Most specialty pharmacy medications require prior authorization from CareSource North Carolina Co. Access our pharmacy policies by selecting Policies from the Quick Links for more information.

How to Submit an Outpatient Specialty Medication Prior Authorization

Outpatient Pharmacy Benefit

  • ePA – Utilize CoverMyMeds or SureScripts prior authorization portals.
  • Pharmacy Benefit Fax – 1-866-930-0019
  • Emergency situations – Requests may be accepted by phone in emergency situations. Providers should contact 1-833-230-2101 and follow the prompts from Pharmacy.

Outpatient Drugs Covered under the Medical Benefit

Prior Authorization Forms

Policies

CareSource North Carolina Co. pharmacy and medical 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 outpatient drugs.

The policies are written for those outpatient drugs that are non-formulary, formulary 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 North Carolina Co. has a process that allows the member or the member’s representative to make a request for an exception. Reasons for exceptions may include intolerance to drugs, allergies to drugs, or inadequate/inappropriate response to drugs listed on the formulary. The Exception Request process is detailed in administrative policies available through the Quick Links, which can be found on the left side of this webpage. The member or member’s representative can call Member Services to make the request or complete the online Member Exception Request for Non-Formulary Medication.

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 North Carolina Co. 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

For most home infusion therapy services, CareSource North Carolina Co. does 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.

Maximum Allowable Cost (MAC)

CareSource North Carolina Co. 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 ESI Appeals Process instructions.

Pharmaceutical Management Procedures

To learn more about how to use our pharmaceutical management procedures, look in the drug formulary. CareSource North Carolina Co. 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.