CurrentCareSource GeorgiaPolicy PAD-0013-GA MCD

Medical Benefit Medications

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This policy governs coverage and payment review for medications administered by a healthcare provider or in a supervised healthcare setting and billed under the medical benefit for CareSource Georgia Medicaid members. It establishes general prior authorization, preferred-drug, medical-necessity, and reauthorization requirements, subject to member benefit plans and drug-specific criteria.

Policy Summary

PayerCareSource Georgia

PolicyMedical Benefit Medications

Policy CodePolicy N/A

Change TypeRevised

Effective DateMar 1, 2026

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

The review and revision history records the addition of reauthorization criteria.

3Initial medical-necessity criteria

4Documented exceptions for non-preferred drugs

3Reauthorization requirements

FDA/compendia/guidelinesEvidence support

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CurrentCareSource GeorgiaPolicy PAD-0013-GA MCD

Medical Benefit Medications

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Sign up for caresourcegeorgia Policy PAD-0013-GA MCD alerts

Get alerted when Policy PAD-0013-GA MCD changes without checking for updates manually.

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Policy Summary

PayerCareSource Georgia

PolicyMedical Benefit Medications

Policy CodePolicy N/A

Change TypeRevised

Effective DateMar 1, 2026

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

The review and revision history records the addition of reauthorization criteria.

3Initial medical-necessity criteria

4Documented exceptions for non-preferred drugs

3Reauthorization requirements

FDA/compendia/guidelinesEvidence support

Coverage Criteria

Initial Therapy

Covered when ALL of the following Medical Benefit Drug medical-necessity criteria are met:

A prior authorization request is submitted for each Medical Benefit Drug with chart notes and member-specific documentation.

The member's indication, dose, and duration for use of the requested Medical Benefit Drug are approved by the Food and Drug Administration (FDA), or are supported by the compendia, current peer-reviewed literature, or evidence-based guidelines.

ONE of the following is true:

The Medical Benefit Drug is a Preferred Drug by CareSource.
The member is unable to take the Preferred Drug(s) because ONE of the following applies:
- 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.
- The Marketplace Preferred Drug(s) is/are not recommended based on published guidelines or clinical literature.
- The Marketplace Preferred Drug(s) is/are expected to be ineffective or less effective for the member based on submitted documentation and medical history.
- The Marketplace Preferred Drug(s) is/are expected to cause an adverse effect based on submitted documentation and medical history.

Reauthorization

Reauthorization requires ALL of the following continuation criteria:

Documentation has been provided showing the member has had a positive response to therapy.

Documentation has been provided showing the member is compliant with therapy.

The requested use and dosage remain consistent with FDA-approved prescribing information in the drug package insert.

Provider Actions and Documentation

Prior Authorization

Prior Authorization Required

Submit a prior authorization request for each Medical Benefit Drug before payment approval. Requests are subject to review and approval by a pharmacist and/or medical director and do not supersede drug-specific clinical criteria approved by the CareSource P&T Committee.

Submit a separate request for each Medical Benefit Drug.
Include chart notes and member-specific documentation with the request.

Step Therapy

Preferred Drug Requirement and Exceptions

The requested Medical Benefit Drug must be a CareSource Preferred Drug unless the member cannot take the Preferred Drug(s) and a documented exception applies.

The member has a clinical condition for which no Marketplace Preferred Drug and/or suitable dosage form is available.
Published guidelines or clinical literature do not recommend the Marketplace Preferred Drug(s).

Policy Background

CareSource Pharmacy Policy Statements are used to encourage appropriate drug selection based on product labeling, clinical guidelines, and clinical studies, while also encouraging use of Marketplace preferred drugs. They provide coverage guidance for providers and must be interpreted with the member’s specific benefit plan. For medical benefit medications, selection and coverage considerations reflect clinical effectiveness, applicable evidence, and preferred-drug status.

Definitions

Administrative Review/Approval/Denial

DefinitionA decision for coverage or non-coverage of a drug.

BasisMade according to a member's benefits, policies and procedures, and applicable legislation and regulation.

Clinical expertiseDoes not require clinical expertise or subject knowledge.

Clinical Judgement

DefinitionA decision made within the scope and expertise of a pharmacist.

Review basisFollows review of subjective and objective medical data for a member.

Use and escalation

Initial Therapy

Initial Therapy Criteria

Medical Benefit Drug coverage requires ALL initial medical-necessity criteria and either Preferred Drug status or a documented exception:

Initial medical-necessity criteria

Prior authorization documentation: Submit a prior authorization request for each Medical Benefit Drug with chart notes and member-specific documentation.
Evidence-supported use: The indication, dose, and duration for use of the requested Medical Benefit Drug are approved by the FDA or supported by compendia, current peer-reviewed literature, or evidence-based guidelines.
Preferred Drug status or documented exception
- Preferred Drug status: The requested Medical Benefit Drug is a CareSource Preferred Drug.

Reauthorization

Continuation Criteria

For reauthorization, ALL of the following are required:

Continuation criteria

Positive response: Documentation has been provided showing the member has had a positive response to therapy.
Compliance with therapy: Documentation has been provided showing the member is compliant with therapy.
Consistency with prescribing information: The requested use and dosage remain consistent with FDA-approved prescribing information in the drug package insert.

Preferred Drug and Step-Therapy Requirement

Step	Requirement
1	Use a CareSource Marketplace Preferred Drug unless a documented clinical or evidence-based exception establishes that the member cannot use the Preferred Drug.

Policy Summary

PayerCareSource Georgia

PolicyMedical Benefit Medications

Policy CodePolicy N/A

Change TypeRevised

Effective DateMar 1, 2026

Next Review DateN/A

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

SourceLink

On This Page

The Marketplace Preferred Drug(s) are expected to be ineffective or less effective for the member based on submitted documentation and medical history.

The Marketplace Preferred Drug(s) are expected to cause an adverse effect based on submitted documentation and medical history.

Documentation Required

Initial Request Documentation

For an initial request, provide chart notes and member-specific support for the requested Medical Benefit Drug, including the member’s indication, dose, and duration. The requested use must be FDA-approved or supported by compendia, current peer-reviewed literature, or evidence-based guidelines.

Document the member-specific indication.
Document the requested dose and duration.
Provide chart notes supporting the diagnosis and medical necessity.
Identify the FDA labeling, compendia, peer-reviewed literature, or evidence-based guideline supporting the requested use when it is not FDA-approved.

Documentation Required

Reauthorization Documentation

For reauthorization, submit documentation showing that the member has had a positive response to therapy and is compliant with therapy. The requested use and dosage must remain consistent with the FDA-approved prescribing information in the drug package insert.

Document positive response to therapy.
Document compliance with therapy.
Confirm continued consistency with FDA-approved prescribing information.

Denial Risk

Initial Criteria and Documentation Must Be Met

Coverage may be denied when the request does not satisfy the applicable medical-necessity criteria or when required initial-request documentation is missing or insufficient.

Prior authorization was not submitted for the Medical Benefit Drug.
Chart notes or member-specific documentation were not provided.
The indication, dose, or duration lacks FDA, compendia, peer-reviewed literature, or evidence-based guideline support.
The Preferred Drug requirement or a documented exception is not satisfied.

Denial Risk

Reauthorization Criteria Must Be Met

Reauthorization may be denied when the record does not demonstrate a positive response and compliance with therapy, or when the requested use or dosage is no longer consistent with FDA-approved prescribing information.

No documentation of positive response to therapy.
No documentation of compliance with therapy.
Requested use or dosage is inconsistent with the drug package insert.

May be used for benefit determination of an exceptions request for a Medical Benefit Drug; requests outside the pharmacist's expertise are determined in collaboration with a medical director.

Drug

DefinitionA medication or substance that induces a physiologic effect on a member's body.

IncludesMedication, agent, drug therapy, treatment, product, or biosimilar drug.

ScopeThe term includes products and therapies that produce a physiologic effect on the member.

Medical Benefit Drug

DefinitionA drug usually administered by a healthcare provider or in a supervised healthcare setting.

BillingBilled to CareSource through the medical benefit.

Member cost sharingSubject to the appropriate member cost share based on the Schedule of Benefits and/or Summary of Benefits and Coverage.

Non-Preferred Drug

DefinitionA drug determined to be less clinically efficacious or cost-effective for an FDA-approved use than other available drugs.

Determining bodyThe determination is made by the CareSource P&T Committee.

ComparisonStatus reflects comparison with other available drugs for the same FDA-approved use.

Preferred Drug

DefinitionThe CareSource drug of choice for an FDA-approved use.

DesignationIdentified on a Pharmacy Policy Statement available on the CareSource website.

Selection basisSelected based on clinical efficacy and cost as determined by the CareSource P&T Committee.

Specialty Drug

DefinitionA drug that treats highly complex diseases or requires special handling or distribution.

CostUsually high cost.

AuthorizationMany Specialty Drugs require prior authorization.

DistributionMay be dispensed at limited locations; see CareSource's Specialty Drug List on the CareSource website.

Documented inability to use the Preferred Drug

No suitable preferred option: There is no Marketplace Preferred Drug and/or needed dosage form suitable to treat the member's diagnosis.
Not recommended: The Marketplace Preferred Drug(s) is/are not recommended based on published guidelines or clinical literature.
Expected ineffectiveness: The Marketplace Preferred Drug(s) is/are expected to be ineffective or less effective for the member based on submitted documentation and medical history.
Expected adverse effect: The Marketplace Preferred Drug(s) is/are expected to cause an adverse effect based on submitted documentation and medical history.