Member : Pharmacy Information

PREFERRED DRUG LISTING

WellCare of Ohio covers medically necessary drugs that are required by Medicaid. It is important to know we use a Preferred Drug List (PDL). These are the drugs that we prefer that your doctor prescribe.  Most medications on the PDL are covered without prior authorization or Drug Evaluation Review (DER).  However, some PDL items require prior authorization and are only covered with at PA/DER.  Medications that require a PA/DER are noted with a “PA” (prior authorization) or "ST" (step therapy) listed next to the medication.  All non-PDL medications require a prior authorization. 

The PDL will also have drugs that may have limits due to your age or the quantity prescribed. These are noted on the PDL with an "AL" (age limit) and "QL" (quantity limit).

Your doctor will need to submit a PA/DER Request Form for the following:

• Drugs not listed on the PDL
• Drugs listed on the PDL but still requiring prior authorization;
• Most self-injectable and infusion drugs;
• Brand name drugs when a generic exists;
• Drugs that have an age limit (AL);
• Prescriptions that exceed the Food and Drug Administration (FDA) daily or monthly quantity limits; and
• Drugs with a step edit (ST) therapy is inappropriate

To get authorization, your doctor must submit the appropriate PA/DER form to the WellCare Pharmacy department.  The fax number is 1-877-277-6892.  The WellCare Pharmacy department will answer all requests within 24 hours. 

Need to know whether a drug is on the preferred list?  Want to know which drugs need authorization?  Click the proper link below.  
 

Click here for the Preferred Drug Listing

Click here for the abbreviated Preferred Drug Listing

Click here for the Medicaid Cough and Cold Listing

Click here for Drugs Requiring Authorization

Generic Medications

Generic drugs usually work as well as the name brand and cost less.  In order to receive a name brand when a generic is available, there must be a medical reason.  An exception request should be filled out on the PA/DER form. 

Coverage Limitations

The following list of non-covered (excluded) drugs and/or categories from the PDL:

• Agents used for anorexia or weight gain/loss;
• Agents used for erectile dysfunction;
• Agents used to promote fertility;
• Agents used for cosmetic purposes or hair growth;
• Non-prescriptive drugs (OTC drugs*) with a few exceptions listed on the PDL;
• Medications prescribed for any indication that is not medically accepted;
• DESI drugs or drugs that may have been determined to be identical, similar or related;
• Vitamin or mineral products, including prenatals or fluoride preparations, except for those listed on the PDL;
• Investigational or experimental drugs; and
• Agents prescribed for any indication that is not medically accepted

Q.  Will I be required to use a generic drug when a brand is available?

A.  Generic drugs must be dispensed by the pharmacist when available as the therapeutically equivalent to a brand name drug.  In order to receive a name brand when a generic is available, there must be a medical reason.  An exception request should be filled out on a PA/DER form.

Q.  What is the difference between brand-name and generic drugs?

A. Generic drugs work the same as brand drugs.  They both have the same active ingredients.

Pharmacy Forms

• Click here for the Coverage Determination Request Form
• Click here for the Direct Member Reimbursement Form
• Click here for the Enteral Nutrition Form
• Click here for the Abbott Meter Request Form
• Click here for the Injectable Infusion Form
• Click here for the Synagis Request Form
• Click here for the Medication Appeal Request Form
• Click here for the Accu-Chek Meter Request Form

Coverage

• Coverage determination request
• Coverage redetermination request