Prior Authorization, Step Therapy & Quantity Limitations | Allwell from Silver Summit Health

Prior Authorization, Step Therapy and Quantity Limits

Our plan has a team of doctors and pharmacists who create tools to help us provide you quality coverage. Examples are:

  • Prior Authorization: We require you to get approval from us before we agree to cover certain drugs. We call this prior authorization. If you don’t get approval, you may be asked to pay for the drug. 
  • Step Therapy: In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. 
  • Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover. For example, one tablet per day. This may be in addition to a standard one-month or three-month supply.

Prior Authorization Criteria:

List of Drugs — Group A:

  • WellCare Specialty No Premium P3 (HMO C-SNP)
  • WellCare Specialty No Premium USHS (HMO C-SNP)

List of Drugs — Group B:

  • WellCare Dual Access (HMO D-SNP)
  • WellCare Dual Access P3 (HMO-DSNP)
  • WellCare Dual Access USHS (HMO-DSNP)
  • WellCare Assist (HMO)
  • WellCare Assist P3 (HMO)
  • WellCare Assist USHS (HMO)

List of Drugs — Group C:

  • WellCare No Premium (HMO)
  • WellCare No Premium P3 (HMO)
  • WellCare No Premium USHS (HMO)
  • WellCare No Premium Open (PPO)
  • WellCare Giveback (HMO)
  • WellCare Giveback P3 (HMO)
  • WellCare Giveback USHS (HMO)

Step Therapy Criteria:

List of Drugs — Group A:

  • WellCare Specialty No Premium P3 (HMO C-SNP)
  • WellCare Specialty No Premium USHS (HMO C-SNP)

List of Drugs — Group B:

  • WellCare Dual Access (HMO D-SNP)
  • WellCare Dual Access P3 (HMO-DSNP)
  • WellCare Dual Access USHS (HMO-DSNP)
  • WellCare Assist (HMO)
  • WellCare Assist P3 (HMO)
  • WellCare Assist USHS (HMO)

List of Drugs — Group C:

  • WellCare No Premium (HMO)
  • WellCare No Premium P3 (HMO)
  • WellCare No Premium USHS (HMO)
  • WellCare No Premium Open (PPO)
  • WellCare Giveback (HMO)
  • WellCare Giveback P3 (HMO)
  • WellCare Giveback USHS (HMO)

 

Quantity Limits:  Refer to the List of Drugs (Formulary) for drug requirements and limits.

You can ask us to make an exception to our coverage rules. For specific types of exceptions, refer to the Evidence of Coverage.

We must decide within 72 hours of getting your doctor’s supporting statement. You or your doctor can request a fast (expedited) exception if your health may be harmed by waiting. Your doctor must submit a supporting statement with the Coverage Determination Form. If we grant your request, we must give you a decision no later than 24 hours after we get your doctor’s supporting statement.

Refer to the Coverage Determinations and Redeterminations page for more information.

If you have questions or want to get the most recent list of drugs, contact Member Services. We are here to help.