Medical Benefit Drugs administrative policy
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Governs prior authorization, documentation, site-of-care, and reauthorization requirements for medications billed to the medical benefit for CareSource members (Arkansas PASSE context). Affects providers requesting coverage for medical benefit medications.
No material clinical or coverage changes in this revision.
Medical Necessity and Coverage Criteria
Medical Necessity Criteria
CareSource considers a Medical Benefit Drug medically necessary when ALL of the following criteria are met:
ALL of the following
- Prior Authorization with chart notes and member-specific documentation submitted
- Indication, dose, and duration are FDA-approved or supported by compendia, current peer-reviewed literature, or evidence-based guidelines
ONE of
- Requested drug is a CareSource Preferred Drug
- Member is unable to take Preferred Drug(s) because there is no suitable Preferred drug or needed dosage form for the diagnosis
- Preferred Drug(s) are not recommended based on published guidelines or clinical literature
- Preferred Drug(s) are expected to be ineffective or less effective for the member based on submitted documentation and medical history
- Preferred Drug(s) are expected to cause an adverse effect for the member based on submitted documentation and medical history
ALL of the following
- If requested agent has a self-administered dosage form available, include rationale why member cannot utilize the self-administered version (self-administered drugs are generally not covered under the medical benefit)
- If managed under Arkansas PDL or PAD program, apply those criteria
ALL of the following
- Documentation that the drug will be administered in the appropriate site of care
- For reauthorization, documentation of positive response, compliance, and dosing consistent with FDA labeling is required
Coding References
| No codes listed |
Prior Authorization, Authorization Period, and Reauthorization
Prior Authorization and Review
Submit a Prior Authorization request for each Medical Benefit Drug including chart notes and member-specific documentation; approvals may require pharmacist and/or medical director review.
- Include indication, dose, and duration documentation showing FDA approval or support from compendia/peer-reviewed literature/guidelines.
- If a self‑administered dosage form exists, include rationale why the member cannot use it (self‑administered drugs are generally not covered under the medical benefit).
Authorization Period Determination
The authorization period is set by the approving pharmacist using clinical judgement.
Reauthorization Requirements
For reauthorization, provide documentation showing a positive response to therapy, member compliance, and that the requested use and dosage remain consistent with FDA‑approved prescribing information.
- Documentation of positive clinical response to the drug.
- Documentation of adherence/compliance with the prescribed therapy.
- Current dosing and indication must match FDA‑approved prescribing information in the package insert.
Definitions
Reauthorization / Continuation Criteria
Reauthorization
Reauthorization/continuation therapy is approved only when ALL of the following are documented:
ALL of the following
- Documentation of a positive clinical response to therapy
- Documentation demonstrating member compliance with the prescribed therapy
- Requested use and dosage remain consistent with FDA‑approved prescribing information (drug package insert)
Site-of-Care Requirements
Document appropriate site of care and rationale for medical‑benefit billing of self‑administered formulations
Provide documentation that the drug will be administered in the appropriate site of care; if a self‑administered formulation is available and the drug is billed to the medical benefit, include rationale why the member cannot use the self‑administered version (self‑administered drugs are generally not covered under the medical benefit).
- Document planned site of administration (e.g., infusion center) is appropriate
- If a self‑administered dosage form exists, include rationale why the member cannot use it
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