Pharmacy

Before providing care or prescribing medicine for your patients, please review the CareSource MyCare Ohio (Medicare-Medicaid Plan) Formulary and the Changes. 

To make your search easy, use the Formulary Search Tool to look up covered drugs and criteria.

Formulary

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

Copayments

Type of CoverageCopayment

Members who have CareSource MyCare Ohio coverage for both Medicare and Medicaid

no copays for covered Part D prescription and over-the-counter (OTC) drugs

Members who have CareSource MyCare Ohio coverage for Medicaid 

only may have copays for Medicare Part D drugs that are received through their Medicare health care plan

Note: Members can contact their Medicare plan to determine if they have Medicare Part D drug copays. For non-Part D prescription and OTC drugs, these members will not have any copays for covered, non-Medicare drugs.

Formulary Exceptions

During the course of a member’s medical care, there may be instances when a member requires a non-formulary drug or a drug that has formulary limits or restrictions (e.g., step therapy requirements, prior authorization or quantity limits):

If a medication requires step therapy or prior authorization, use the Navigate Request for Medicare Prescription Drug Coverage Determination form. This form can also be completed and submitted online. 

CareSource MyCare Ohio may approve an exception request for a non-formulary drug or a drug that has formulary limits or restrictions when medically necessary. To determine medical necessity, CareSource MyCare Ohio will verify, through the provider’s supporting statement(s) and/or standards documented in clinical guidelines adopted by CareSource MyCare Ohio, that:

  • The member has tried and failed and/or has documented contradictions or intolerance to the equivalent formulary medications, and
  • No other formulary agent is appropriate to treat the member’s condition.

Exception requests will be processed through CareSource MyCare Ohio’s Pharmacy Benefit Manager (PBM) prior authorization review process.

Tiered Medications

Medications are classified using the following tier levels:

  • Tier 1: Medicare Part D Generic Drugs
  • Tier 2: Medicare Part D Preferred Brand Drugs
  • Tier 3: Non-Medicare Covered Prescription & OTC Drugs

Prior Authorization Review Process

CareSource MyCare Ohio will process coverage determinations and exception requests in accordance with Medicare Part D regulations. Requests will be handled through the prior authorization review process. Prior authorization requires a drug to be “pre-approved” in order for it to be covered under a benefit plan.

The prior authorization staff will adhere to the CareSource MyCare Ohio Centers for Medicare & Medicaid Services (CMS) approved criteria. The PBM’s National Pharmacy and Therapeutics Committee establishes clinical guidelines and other professionally recognized standards to review each case, rendering a decision based on established protocols and guidelines.

Providers can submit requests by any of the methods identified below. Providers are required to submit pertinent medical/drug history, prior treatment history and any other necessary supporting clinical information with the request. Standard requests will be reviewed and determinations will be made within 72 hours.

Expedited or urgent requests will be reviewed and determinations will be made in 24 hours. A request is considered urgent if the requester believes that applying the standard process may seriously jeopardize the member’s life, health or ability to regain maximum function. Providers will be notified by phone or fax of the determination.

Prescribers or their designated agents may request authorization by one of the following mechanisms:

  • Online submission
  • Navigate Form for office use
  • Written request via fax: 1-877-251-5896 for oral medications and injectable/specialty medications
  • Toll-free phone number: 1-800-935-6103

For more information, please call Provider Services at 1-800-488-0134.