The WellCare Georgia 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 NIH Asthma guideline, JNC VII Hypertension guidelines
• Prescribe drugs from the Preferred Drug List (PDL) 
• Prescribe generic drugs when therapeutic equivalent drugs are available
• Evaluate medication profiles for appropriateness and duplication of therapy

Coverage Limitations

The following is a list of Non-covered (excluded) drugs and/or categories from the PDL

• Agents used for anorexia or weight gain
• Agents used to promote fertility
• Agents used for cosmetic purposes or hair growth
• Agents used to promote smoking cessation
• Barbiturates, except Seconal, Phenobarbital and Mebaral
• Prescription vitamins and mineral products, EXCEPT prenatal vitamins and fluoride preparations that are not in combination with other vitamins and Carnitor. Vitamin E and Coenzyme Q are covered under medical necessity for members under 21 years of age. Folic acid 1 mg is covered.
• Certain Calcium, Aluminum, Pyridoxine, Thiamine and Vitamin B preparations EXCEPT when used for ERSD certified by the physician. (See PDL for current list)
• Nonprescriptive drugs (OTC drugs) with a few EXCEPTIONS listed on the PDL (All covered OTC drugs require a prescription.)
• Brand benzodiazepines for members over 21 years of age requiring more than three prescriptions per calendar year. (See PDL for drug and qty limit.)
• Topical Vitamin A derivatives for members over 21 years of age
• Agents prescribed for any indication that is not medically accepted
• Agents when used for the symptomatic relief of cough and colds for members over 21 years of age

The Plan will not reimburse for prescriptions for refills too soon, duplicate therapy or excessively high dosages for the member.

Step-Therapy Programs

Step-therapy programs are developed by the Pharmaceutical and Therapeutics Committee (P&T Committee). This program is designed to provide our members with clinically sound, cost-effective drug treatment options. Step-therapy programs encourage the use of select therapies before alternative therapies are prescribed. They follow an extensive review of clinical literature, manufacturer product information and consultation with medical professionals to assure a clinically comprehensive program.

Please refer to the PDL to view drugs requiring step therapy.

Over the Counter (OTC)

The following Over the Counter (OTC) medications are available to the member with a prescription. (See the PDL for a complete list of available OTC drugs.) 

• Multivitamins and multiple vitamins with iron for members under 21 years of age (chewable or liquid drops)
• Iron
• Proton Pump Inhibitors
• Non-sedation Antihistamines
• Enteric-coated aspirin
• Diphenydramine
• Insulin
• Topical Antifungal
• Ibuprofen Suspension for members under 21 years of age
• Lice B Gone
• Meclizine
• Insulin Syringe
• Urine Test Strips
• H-2 Receptor antagonist 

Patient Co-payments

There are co-pay requirements for members prescribed legend and over-the-counter drug products. All covered services require a written prescription from an authorized Prescriber. Below is the co-pay structure.

Prescription Drug
If Drug Cost is:	Co-pay (member pays)
Less than $ 10.01	$ .50 cents
Between $10.01 - $ 25.00	$ 1.00
Between $ 25.01 - $ 50.00	$ 2.00
Greater than $ 50.01	$ 3.00

Co-pays are not required for family planning services, children under the age of 21, pregnant women, nursing home facility residents and hospice care members.

Drug Evaluation Review Process

The goal of the Drug Evaluation Review (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. The DER process is required for: 

• Duplication of therapy
• Prescriptions that exceed the FDA daily or monthly quantity maximum
• Self-injectable and infusion medications other than insulin
• Drugs not on the PDL
• Prescriptions that exceed $500/prescription (some exceptions apply), and/or plan limitations
• Prescriptions processed by non-network pharmacies

Unless the request is for an urgent medication, drug evaluation requests are accepted by fax only at 1-866-455-6558. 

Related Links: 

Georgia Medicare
Georgia Medicaid

Pharmacy forms are available in the Georgia Medicare Provider handbook or Georgia Medicaid Provider handbook.