Provider : Pharmacyservicesnewyork

Important Pharmacy Benefit Change

Beginning October 1, 2011, the pharmacy prescription benefit for your patient(s) enrolled in Healthy Choice and Family Health Plus will be managed by WellCare of New York, Inc.

 WellCare will be using Catalyst Rx to provide your patient(s) pharmacy benefit. Starting October 1, 2011, when your patient(s) need to fill a prescription, they must go to a pharmacy in the Catalyst Rx network. Your patient(s) co-payments for drugs will not change.

 Click here for more information.

The WellCare of New York 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
 

Pharmacy Forms
Abbott Meter Form
Accu-Chek Meter Form
Enteral Nutrition Form
Injectable-Infusion Form
Drug Evaluation Review Form
Synagis Request Form
DMR 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 other than prenatal or fluoride preparations;
• Investigational or experimental drugs
• Agents prescribed for any indication that is not medically accepted; and
The Plan 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
The Preferred Drug List (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.
Most medications on the Preferred Drug List (PDL) are covered without prior authorization or Drug Evaluation Review (DER). However, some PDL items are only covered with a Drug Evaluation Review (DER). Medications that require a Drug Evaluation Review are noted with a “DER” (drug evaluation review) or “ST” (step therapy) listed next to the medication. All non-PDL medications require the submission of a DER request.

Preferred Drug List

Preferred Drug List Abbreviated

NY Medicaid Cough Cold Drug List

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.
• Duplication of therapy
• Prescriptions that exceed the FDA daily or monthly quantity limit;
• Most self-injectable and infusion medications;
• Drugs not listed on the Preferred Drug List (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.

Unless the request is for an urgent medication, drug evaluation requests are accepted by fax only at 1-866-388-1517. To obtain an expedited request please check the expedited box on the Drug Evaluation Request Form. All requests will be completed within 24 hours. For an emergency supply of medication or for any questions related to authorizations, please call 1-800-288-5441.

Medical Injectables Prior Authorization Requirements:
WellCare continuously strives to reduce barriers to care and therapies. In reviewing our medical injectable prior authorization requirements, WellCare 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  - Effective December 7, 2010
 

DME
All durable medical equipment (DME) and medical supplies, including diapers, crutches, bandages, liquid nutritional supplements, hearing aid batteries and other supplies will not be covered at the pharmacy.  These items will need to be approved through the DME process.  Requests are accepted by telephone or fax.  Please call Customer Service at 1-800-288-5441 Monday-Friday, 8:00 AM- 6:00 PM ET.  Fax requests to 1-877-431-8859.  Diabetic supplies (including meters, strips, lancets, and alcohol swabs) are covered at the pharmacy. 
 

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
 

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.
 

NMD  
Brand Drugs $3
Generics $1
Covered OTC $0.50
Covered Diabetic Supplies $0
 

FHP 
Brand Drugs $6
Generics $3
Covered OTC $0.50
Covered Diabetic Supplies $0
 

Co-pays are not required for:
• Consumers younger than 21 years old.
• Consumers who are pregnant. Pregnant women are exempt during pregnancy and for the two months after the month in which the pregnancy ends.
• Consumers in a Comprehensive Medicaid Case Management (CMCM) or Service Coordination Program.
• Consumers in an OMH or OPWDD Home and Community Based Services (HCBS) Waiver Program.
• Consumers in a DOH HCBS Waiver Program for Persons with Traumatic Brain Injury (TBI).
• Family Planning drugs and supplies like birth control pills and condoms.
• Drugs to treat mental illness (psychotropic) and tuberculosis