The management of outpatient prescription medications is an integral part of the medical management program and is necessary to improve the health and well being of our members. Provider and member involvement is critical to the success of the pharmacy program. Therefore, in order to help your patients get the most out of their pharmacy benefit, please be cognizant of the following guidelines when prescribing:

• Follow such national standard-of-care guidelines as the NIH Asthma Guidelines and JNC VII Hypertension Guidelines

• Prescribe generic medications whenever a therapeutic equivalent medication
  is available

• Evaluate medication profiles for appropriateness and duplication of therapy

Coverage Limitations
The following is a list of non-covered (excluded) medications and/or categories:

• Drugs for the treatment of infertility

• Drugs used for weight loss

• Drugs for the treatment of erectile dysfunction

• Drugs used for cosmetic purposes

• Experimental drugs

• Cough and cold combination medications for  members 21 and older

• Drugs used to promote hair growth

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 Drug Evaluation Review (DER) form.

Pharmacy Forms 

The following pharmacy forms are available on the New York Provider Manual Forms page.

• Abbott Meter Form

• Accu-Chek Meter Form

• Enteral Nutrition Form

• Injectable-Infusion Form

• Drug Evaluation Review Form

Pharmacy Services – Family Health Plus

Beginning October 1, 2008, the pharmacy prescription benefit for WellCare of New York Family Health Plus members will be managed by the New York State Department of Health (NYSDOH) on a fee-for-service basis.

The New York state fee-for-service program preferred drug list may be found here.