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CareSource Formulary Change Update

posted: May 20, 2019

OAR received notice in March that changes would be made to the CareSource Formulary effective April 1, 2019 concerning the removal of Humira for RA indications from the CareSource formulary for OH Medicaid beneficiaries. OAR requested that CareSource maintain continuity of care for patients who are currently stable and grandfather coverage for Humira at the previous benefit level. OAR expressed concerns about the change in a letter to the OH Medicaid Director and members of the JMOC. A copy of the letter was also distributed on advocacy day at the various meetings the OAR advocates attended.

OAR later learned that CareSource was telling some legislators that patients who were stable on Humira prior to April 1, 2019 would be “grandfathered in” and would thereby be able to remain on their treatment if an exemption was requested by the provider; suggesting the restriction for coverage would only apply to those not on Humira prior to April 1.

However, OAR government affairs have been made aware that some exemptions and appeals for patients to remain on Humira have been denied. Given these occurrences, OAR is skeptical as to whether CareSource is acting in good faith and in congruence with what they have been telling lawmakers.

No official notice to providers or patients has been sent out regarding the purported grandfathering protection for stable patients. Therefore, in order to keep the CareSource formulary issue at the forefront of legislators’ and bureaucrats’ minds, OAR is requesting that you report any exemption and appeal denials for Humira to Heather Kazmark, OAR Government Affairs Specialist, by email at hkazmark@wjweiser.com or by calling (847) 264-5930.

OAR is hopeful that continued conversations and negotiations will be had regarding the removal of Humira from the formulary for RA indications.