Medical Benefit Pharmacy Administrative Policy
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Defines CareSource Marketplace plan rules for coverage determination, prior authorization, and reauthorization of medical-benefit drugs administered in healthcare settings; applies to CareSource Marketplace members and providers submitting requests.
No material clinical or coverage changes in this revision.
Medical Necessity and Coverage Criteria
Medical Necessity and Reauthorization Criteria
Coverage is considered medically necessary when ALL of the following criteria are met:
ALL of the following
ALL of the following
- Prior Authorization request submitted with chart notes and member-specific documentation
- Member's indication, dose, and duration are FDA-approved or supported by compendia, current peer-reviewed literature, or evidence-based guidelines
ONE of the following
- The Medical Benefit Drug is a CareSource Preferred Drug
- Member unable to take Preferred Drug(s) because there is no Marketplace Preferred Drug or suitable dosage form for the diagnosis
- Marketplace Preferred Drug(s) not recommended based on published guidelines or clinical literature
- Marketplace Preferred Drug(s) are expected to be ineffective or less effective for the member based on submitted documentation and medical history
- Marketplace Preferred Drug(s) are expected to cause an adverse effect for the member based on submitted documentation and medical history
ALL of the following
- For reauthorization: Documentation of positive response to therapy
- For reauthorization: Documentation of member compliance with therapy
- For reauthorization: Requested use and dosage remain consistent with FDA-approved prescribing information (drug package insert)
Reauthorization / Continuation Criteria
CONTINUATION CRITERIA
Reauthorization/continuation of therapy is approved when ALL of the following are met:
ALL of the following
- Documentation of positive response to therapy
- Documentation of compliance with therapy
- Requested use and dosage remain consistent with FDA-approved prescribing information (drug package insert)
Prior Authorization, Review, and Authorization Period
Prior Authorization and Review Required for Medical Benefit Drugs
Submit a Prior Authorization request for each Medical Benefit Drug with chart notes and member-specific documentation; approval may include pharmacist review and/or medical director review.
- Include chart notes and member-specific documentation with the request.
- Be aware that approval may require review by a pharmacist and/or the medical director.
Authorization Period Determined by Pharmacist Clinical Judgement
The authorization period for approved Medical Benefit Drug requests will be set based on the approving pharmacist's clinical judgement.
- Pharmacists may use clinical judgement based on subjective and objective medical data to determine the authorization duration.
- If the request falls outside a pharmacist's scope, determination may be made in collaboration with a medical director.
Benefit Classification and Coding
| No codes listed |
Key Definitions
Administration Setting and Billing
Site-of-Care and Medical Benefit Billing
Medical Benefit Drugs are typically administered in supervised healthcare settings (e.g., infusion centers) and are billed to CareSource through the medical benefit.
- Ensure claims are billed through the medical benefit per member’s Schedule of Benefits.
- Administer drugs in an appropriate supervised healthcare setting consistent with definition of Medical Benefit Drug.
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