Medical Benefit Medications — Administrative Policy
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Defines administrative requirements, prior authorization expectations, and conditions of coverage for medical-benefit medications for CareSource Marketplace plan members; applies to providers submitting medical-benefit drug requests to CareSource Georgia.
No material clinical or coverage changes in this revision.
Medical Benefit Drug Coverage Criteria
Medical Benefit Drug Coverage Criteria
Coverage (considered Medically Necessary) when all listed criteria are met:
ALL of the following
- Prior Authorization submitted with chart notes and member-specific documentation
- Requested indication, dose, and duration are FDA-approved or supported in compendia, current peer-reviewed literature, or evidence-based guidelines
ALL of the following
ONE of
- There is no Marketplace Preferred Drug and/or needed dosage form suitable to treat the member's diagnosis
- Marketplace Preferred Drug(s) are 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 based on submitted documentation and medical history
- If a self-administered dosage form exists, documentation must justify the member's inability to use the self-administered version (self-administered drugs are generally not covered under the medical benefit)
- Documentation that the drug will be administered in an appropriate site of care
Billing Code Systems
| HCPCS | Referenced as condition of coverage code set for billing |
| CPT | Referenced as condition of coverage code set for billing |
| AUTHORIZATION PERIOD | as determined by the approving pharmacist's Clinical Judgement |
Provider Action Requirements
Prior Authorization required with chart notes and member-specific documentation
Prior Authorization requests must be submitted for each Medical Benefit Drug and include chart notes and member-specific documentation; approvals may be made by a pharmacist and/or medical director.
- Submit supporting chart notes and member-specific documentation with the PA request.
- Be aware that approval may be delegated to a pharmacist and/or medical director.
Authorization period set by approving pharmacist
The authorization period is determined by the approving pharmacist's clinical judgement.
- Duration of approval is set by the pharmacist based on clinical judgement.
Key Definitions
Reauthorization / Continuation Criteria
Reauthorization
Reauthorization requirements
ALL of the following
- Documentation of a positive response to therapy
- Documentation that the member is compliant with therapy
- Requested use and dosage remain consistent with FDA-approved prescribing information (drug package insert)
Site of Care Documentation Requirements
Document planned site of care and justify use of non–self-administered formulation
Include documentation that the drug will be administered in an appropriate site of care; self-administered formulations are generally not covered under the medical benefit unless a rationale for inability to self-administer is provided.
- Document planned administration site (e.g., infusion center) for the requested drug
- If a self-administered dosage form exists, provide justification why the member cannot use it
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