CurrentCareSourcePolicy PAD-0898-AR-PASSE

Medical Benefit Medications (Administrative Policy Statement - Arkansas PASSE)

Defines CareSource's administrative policy framework for coverage review and approval of medications billed to the medical benefit for Arkansas PASSE members, including prior authorization and reauthorization requirements.

Policy Summary

PayerCareSource

PolicyMedical Benefit Medications (Administrative Policy Statement - Arkansas PASSE)

Policy CodePolicy PAD-0898-AR-PASSE

Change TypeAdded reauthorization criteria

Effective DateOct 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests with chart notes and member-specific documentation for each Medical Benefit Drug.

SourceLink

POLICY UPDATE CHANGES

Added reauthorization criteria.

Removed the phrase 'Medical Necessity' to align with new policy titles.

10/01/2025effective date

Addedreauthorization criteria

Administrativepolicy type

PAD-0898-AR-PASSEpolicy ref

Coverage Criteria

Policy Summary

PayerCareSource

PolicyMedical Benefit Medications (Administrative Policy Statement - Arkansas PASSE)

Policy CodePolicy PAD-0898-AR-PASSE

Change TypeAdded reauthorization criteria

Effective DateOct 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests with chart notes and member-specific documentation for each Medical Benefit Drug.

SourceLink

On This Page

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Medical Benefit Drug approval criteria: (1) Prior Authorization requests should be submitted for each Medical Benefit Drug with chart notes and member-specific documentation; AND (2) One of the following is true: the member's indication, dose, and duration for the use of the requested Medical Benefit Drug is approved by the Food & Drug Administration (FDA) or an indication supported in the compendia or current peer-reviewed literature or evidence-based guidelines AND (a) The Medical Benefit Drug is a Preferred Drug by CareSource OR (b) The member has a clinical condition for which there is no Marketplace Preferred Drug and/or needed dosage form suitable to treat the member's diagnosis OR (c) The member is unable to take the Preferred Drug(s) because the Marketplace Preferred Drug(s) are not recommended based on published guidelines or clinical literature OR are expected to cause an adverse effect based on submitted documentation and medical history; OR (3) The Marketplace Preferred Drug(s) are expected to be ineffective or less effective for the member based on submitted documentation and medical history.

Text preserves document's AND/OR structure; original numbering and alternatives retained.

inv-02: Reauthorization

For reauthorization, ALL of the following must be provided:

Reauthorization: (1) Documentation has been provided showing the member is compliant with therapy; AND (2) Documentation has been provided showing the member has had a positive response to therapy; AND (3) The requested use and dosage remain consistent with FDA-approved prescribing information in the package insert.

Added to policy as per revision history.

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Medical Benefit Drugs billed to CareSource. Requests must be submitted before therapy is initiated when possible and must include chart notes and member-specific documentation to support medical necessity. Approval may require review by a pharmacist and/or medical director.

Applies to Medical Benefit Drugs requiring medical benefit payment
Requests may be reviewed by a pharmacist and/or medical director

Step Therapy

Step Therapy (general)

CareSource pharmacy policy statements may require step therapy. These policies are interpretive tools and must be applied in conjunction with the member's specific benefit plan. Providers should follow required step therapy edits and document reasons for exceptions when applicable.

Step therapy requirements from the Pharmacy Policy Statement are applied together with the member's benefit plan
Providers may need to document trial and failure of preferred agents or clinical justification for bypassing step therapy

Documentation Required

Documentation to Submit

Prior authorization requests must include member-specific clinical documentation to substantiate the request. Incomplete documentation may delay review or result in denial.

Relevant chart notes and clinical progress notes
Diagnostic test results, laboratory data, or imaging when applicable
Medication history including prior therapies, doses, dates, and reason for discontinuation
Documentation of FDA-approved indication, compendia support, or evidence-based guideline justification when used off-label
For reauthorization: evidence of member compliance and positive response to therapy

Denial Risk

Prior Authorization Submission Requirement

Failure to submit the required documentation with the prior authorization request may result in denial of payment. Providers are responsible for providing sufficient clinical information to support medical necessity; missing or inadequate information may require request denial or a request for additional information which can delay care.

Incomplete requests may be returned or denied
Denial may occur if documentation does not demonstrate medical necessity or step therapy requirements are not met
Provide prompt responses to requests for additional information to avoid delays

Background

CareSource Policy Statements provide guidance to encourage appropriate selection of drug therapy for members by referencing product labeling, clinical guidelines, and clinical studies, and by promoting use of Marketplace preferred drugs where appropriate. These statements are intended as a tool to interpret coverage in the context of a member's specific benefit plan and do not, by themselves, constitute the detailed coverage criteria used for authorization decisions. (Informational introduction — not to be construed as coverage criteria.)

When a medication is billed to the medical benefit, Medical Benefit Drugs may require review and approval by a pharmacist and/or medical director before payment is approved; care decisions follow drug-specific clinical criteria established by the CareSource Pharmacy & Therapeutics Committee and the policy framework described here.

Definitions

inv-08: Medical Benefit Drug

DefinitionA Medical Benefit Drug is a drug that is usually administered by a healthcare provider or in a supervised healthcare setting and is billed to CareSource through the medical benefit.

Billing/Cost ShareSubject to the appropriate member cost share based on the Schedule of Benefits (SOB) and/or Summary of Benefits and Coverage (SBC).

SettingTypically provided in provider-administered or supervised settings rather than retail pharmacy dispensing.

inv-09: Clinical Judgement

DefinitionDecisions made within the scope and expertise of a pharmacist following review of subjective and objective medical data for a member.

ScopeA pharmacist may use clinical judgement for benefit determinations for exception requests for a Medical Benefit; if outside the pharmacist's expertise, determination is made in collaboration with a medical director.

ApplicationApplies to assessment of member-specific clinical information when reviewing prior authorization or exception requests.

inv-10: Preferred / Non-Preferred Drug

Preferred DrugThe drug of choice for CareSource for an FDA‑approved use as indicated on a Pharmacy Policy Statement and based on clinical efficacy and cost as determined by the CareSource P&T Committee.

Non‑Preferred DrugA drug determined by CareSource to be less clinically efficacious or less cost‑effective for an FDA‑approved use than other available drugs by the CareSource P&T Committee.

Basis for DesignationDesignations are made by the CareSource P&T Committee considering clinical efficacy and cost for FDA‑approved uses.