Pharmacy
Preferred Drug List
CareSource utilizes a preferred drug list that is reviewed annually.
CareSource recently updated our preferred drug list and have included a Frequently Asked Questions about these updates.
Generic medications must be used when they are available, unless ineffective and physician must state “dispense as written” on the prescription. Participating CareSource physicians are notified annually of the drugs included in the preferred drug list. Drugs listed in the drug list are covered. In general, this includes:
- Most generic medications.
- Limited over-the-counter, medically necessary medications when prescribed in writing by a licensed medical practitioner.
- One generic 90-day smoking cessation treatment per year.
Formulary medications may require prior authorization, adherence to step-therapy criteria, or quantity limits. Step therapy requires that a first-line preferred medication which is generally accepted as therapeutically equivalent be tried before a second-line preferred or non-preferred medication. Quantity limits have been established on some drugs to align with recommended treatment courses and to help reduce overutilization and abuse.
Exceptions to quantity limits may be granted with medical necessity as prescribed by a provider.
Non-covered medications include:
- Brand name drugs when a generic is available.
- Infertility, cosmetic purposes, obesity drugs or erectile dysfunction.
- Any drug that may be obtained without charge under other local, state or federal programs.
- Any drug labeled “Caution: Limited by federal law to investigational use.”
If you feel it is medically necessary for a member to have a non-preferred drug, please request an exception by forwarding information about the non-preferred drug to CareSource. Please fax the information toll free to 1-866-930-0019 using the request form in the Forms section of the Provider Manual. Your request will be reviewed and a decision made within 24 hours of receipt. If the request is not authorized, you will be notified of the reason. A pharmacist may request a 72-hour supply of medication on all non-preferred medications if clinically required after hours or for emergency situations. Drugs such as fertility, cosmetic and weight-loss medications are considered benefit exclusions and will not be considered.
You may use CareSource’s Ohio Preferred Drug List Look-Up Tool. This is provided in conjunction with our pharmacy benefit manager, Express Scripts. With the tool, you can search for a specific drug by name or browse our preferred drug list by therapeutic class. If you enter a drug that is not on the CareSource list, the tool will provide alternate equivalents.
Or you can call CareSource at 1-800-488-0134. Follow the menu prompts to speak to a pharmacy coordinator. Prior authorization is required for brand name drugs when a generic drug is available. Prior authorization may also be required for other drugs.
To request a prior authorization for a drug complete a Pharmacy Online Prior Authorization Request Form, or call CareSource at 1-800-488-0134 and follow the menu prompts to speak with the pharmacy department. You may also fill out the Request for a Non-Preferred Drug Form and fax it to 1-866-930-0019.
Remember, you may download CareSource's preferred drug list to your PDA from www.ePocrates.com. Thank you for supporting our efforts to control rising pharmacy costs for CareSource members.
Pharmacy Benefit Manager
CareSource holds a contract with RxAmerica for pharmacy benefit management.
You can reach RxAmerica at 1-866-668-0321. For requests after business hours, please call RxAmerica at 1-866-668-0321 to obtain a 72-hour emergency fill.