November 22, 2023
New list is effective January 1, 2024
Step Therapy programs are intended to be a safe and effective method of reducing the cost of treatment by ensuring that an adequate trial of a proven safe and cost-effective therapy is attempted before progressing to a more costly option. First-line drugs are recognized as safe, effective, and economically sound treatments.
The first-line drugs on Wellcare’s formulary have been evaluated through the use of clinical literature and are approved by Wellcare’s Pharmacy and Therapeutics (P&T) Committee. Step therapy is failure of at least one different or less expensive drug prior to coverage of a drug on this list.
Exceptions to use of step therapy
Request prior authorization for Part B drugs subject to step therapy.
The prescriber, patient, or authorized representative may ask for an exception. Step therapy applies if the drug has not been used in the past 365 days.
Access the step therapy list online
To view the Medicare Part B Step Therapy list that is effective January 1, 2024, go to bit.ly/CAWCBulletins.
Verify eligibility and benefits
Be sure to verify eligibility and benefits prior to giving services for all members. Payment, regardless of authorization, depends on the member’s eligibility at the time service is rendered. You can check eligibility when you log onto the provider portal at provider.wellcare.com/California.
Relevant sections of the Wellcare Provider Manual have been revised to reflect the information contained in this update as applicable. The manual is available online at wellcare.com/California/Providers/Medicare.
If you have questions regarding the information contained in this update, contact 1-866‑999‑3945.
This information applies to Physicians, Independent Practice Associations (IPAs), Hospitals, and Ancillary Providers.