Provider : Pharmacy Services

The WellCare of Ohio Pharmacy team is committed to providing its members and providers with the highest-quality service and to partnering with our providers to improve members' health and well-being. To help your patients get the most out of their pharmacy benefit, please be cognizant of the following guidelines when prescribing:

• Follow national standards of care guidelines for treating conditions, such as the National Institutes of Health (NIH) Asthma guideline and the Joint National Committee (JNC) VII Hypertension guidelines;
• Prescribe drugs listed on the Preferred Drug List (PDL);
• Prescribe generic drugs when therapeutic equivalent drugs are available; and
• Evaluate medication profiles for appropriateness and duplication of therapy.

Pharmacy Forms

• Abbott Meter Form
• Accu-Chek Meter Form
• Enteral Nutrition Form
• Injectable-Infusion Form
• Coverage Determination Request Form
• Direct Member Reimbursement Form
• Synagis Request Form
• Appeals Form

Coverage Limitations

• The following is a list of non-covered (excluded) drugs and/or categories from the PDL:
• Agents used for anorexia, weight gain or weight loss;
• 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;
• Drugs for the treatment of erectile dysfunction;
• 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.

WellCare of Ohio will not reimburse prescriptions for refills too soon, duplicate therapy or excessively high dosages for the member.

*All OTC drugs listed on the PDL as covered will require a prescription for the pharmacy to dispense

Preferred Drug List

WellCare of Ohio covers medically necessary drugs that are required by Medicaid. It is important to know we use a Preferred Drug List (PDL). The PDL is a standardized prescribing reference and clinical guide of prescription drug products selected by WellCare’s Pharmacy and Therapeutics Committee. The selection of drugs is based on the drugs’ efficacy, safety, side effects, pharmacokinetics, clinical literature and cost-effectiveness profile.  These are the drugs that we prefer providers to prescribe.

Most medications on the Preferred Drug List (PDL) are covered without a prior authorization (PA)/ drug Evaluation Request (DER). Medications that require a PA/DER are noted with a “PA” or “ST” (step therapy) listed next to the medication. All non-PDL medications require the submission of a PA/DER request.

The PDL will also have drugs that may have limits due to age or the quantity prescribed. These are noted on the PDL with an "AL" (age limit) and "QL" (quantity limit).  Providers will need to submit a PA/DER Request Form for the following:

• Duplication of therapy
• Prescriptions that exceed the FDA daily or monthly quantity limit;
• Most self-injectable and infusion medications;
• Drugs not listed on the PDL;
• Drugs that have an age edit;
• Drugs listed on the PDL but still requiring Prior Authorization (PA);
• Brand name drugs when a generic exists; and
• Drugs that have a step edit (ST) and the first-line therapy is inappropriate.
   

You can find a list of drugs on the preferred drug list by clicking the link below.

• Preferred Drug List
• Abbreviated Preferred Drug List
• Medicaid Cough & Cold Drug List

Prior Authorization/Drug Evaluation Review Process

The goal of the PA/DER program is meant to ensure that medication regimens that are high-risk, have high potential for misuse or have narrow therapeutic indices are used appropriately and according to FDA-approved indications. PA/DER requests are accepted by fax only at 1-877-277-6892. All requests will be completed within 24 hours. For an emergency supply of medication or for any questions related to authorizations, please call 1-800-951-7719.

Medical Injectables Prior-Authorization Requirements:

WellCare of Ohio continuously strives to reduce barriers to care and therapies. In reviewing our medical injectable prior-authorization requirements, WellCare of Ohio identified an opportunity to consolidate and align the list of required codes. We have combined our Medical and Pharmacy injectable prior-authorization code lists into one consistent list, and aligned that list with current industry practice.
 

No Authorization Required Medical Injectable List

Generic Medications

Generic drugs are equally effective and generally less costly than the brand medication. Their use can contribute to cost-effective therapy. Generic drugs must be dispensed by the pharmacist when a drug therapeutically equivalent to a brand-name drug is available. Exceptions to the mandatory generic policy, when therapeutically equivalent options are available, require medical justification. An exception request should be filled out on a PA/DER form.