Pharmacy
As a Qualified Health Plan in the Health Insurance Marketplace, CareSource 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 uses evidence-based guidelines to ensure health care services and drugs meet the standards of excellent medical practice and are the lowest cost alternative for the member. These requirements ensure appropriate use of these drugs.
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 updates the formulary regularly. Visit the Drug Formulary page for more information.
Generic or Biosimilar Substitution
A pharmacy will provide a generic or interchangeable biosimilar drug if available in place of a brand name drug or reference biologic. This is called generic or biosimilar substitution. Members and providers can expect the generic or biosimilar drug to produce the same effect and have the same safety profile as the brand name drug or reference biologic. If a brand name drug or reference biologic is requested when an equivalent generic or biosimilar drug is available, you may need to request a prior authorization. Also, members may pay additional costs for brand name drugs or reference biologics when an equivalent generic or biosimilar is available.
For more information about generic substitution, please refer to the U.S. Food and Drug Administration (FDA) Orange Book. For more information about biosimilar substitution, please refer to the FDA Purple Book.
Prior Authorization, Step Therapy, and Quantity Limits
Refer to the Drug Formulary or Formulary Search Tool to determine which drugs are subject to these restrictions.
NOTE: Opioid drugs will always require prior authorization in the following circumstances:
- The member has already had at least 90 days of therapy in the last 365 days,
- The prescription is for more than 80 morphine milligram equivalents per day,
- The member is receiving concurrent therapy with benzodiazepines, and/or
- The prescription is for an extended-release opioid.
Drugs administered in an outpatient setting by a physician and billed under a member’s medical benefit may also require prior authorization. Refer to the Authorization Requirements for Medications Under the Medical Benefit to determine which drugs require a prior authorization.
Please Note: Effective July 1, 2024, in accordance with West Virginia Senate Bill 267, all prior authorization requests must be submitted electronically via the CareSource Provider 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.
Policies
CareSource 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 prescription drugs.
The policies are written for those prescription 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.
Non-Formulary Drugs and Therapeutic Interchange
CareSource has an exception process that allows the member or the member’s representative to make a request for a formulary exception. Reasons for exceptions may include intolerance to drugs, allergies to formulary drugs, or inadequate/inappropriate response to formulary drugs. 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.
When a non-formulary drug is requested due to drug allergy or intolerance or lack of efficacy of a formulary drug, the prescriber will need to submit supporting clinical documentation just like when requesting a prior authorization. Request for a non-formulary alternative is also called therapeutic interchange.
Home Infusion Therapy
CareSource offers home infusion services to members who require treatment with certain injectable drugs. These services allow members to schedule and receive therapy safely and effectively in the comfort of their own home at a time that works best for their schedule. An infusion-trained nurse will administer the drug and remain with the member during the entire infusion. In most cases, home infusion services will be a lower cost to members through their plan benefits. Members can contact Member Services for more information about transitioning to home infusion therapy.
Maximum Allowable Cost (MAC)
CareSource 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 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.