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Important WellCare Pharmacy Information Memo for Health First Network Physicians

August 3, 2011

Dear Physician Colleagues,

With the 08/01/2011 WellCare Contract Transition underway, a number of offices have presented questions concerning Medications and Infusions given in the office setting to WellCare members, and other related WellCare Pharmacy questions, such as medication pre-authorization requirements.

"The WellCare No-Auth Required List" is a comprehensive, up-to-date listing contains the WellCare Pharmacy Drugs that do not require authorization.

The inference is clear – any J-Code medication given in the office that is not on the list, will require authorization from the WellCare Pharmacy. Per conversation with the WellCare Director of Pharmacy, when a medication requires authorization, it also requires a form called a DER Form (Drug Exception Request, or Drug Evaluation Review Form), or DUR Form (Drug Utilization Request), or Coverage Determination Request Form - Florida. The current form can be found on the hfni website, but is also included in this memo for your convenience (Coverage Determination Request Form – Florida). The form can be used for both WellCare and HealthEase members.

Detailed, specific clinical information on the DER Form is required for approval of all auth-required drugs. Here are the specifics needed:

  • Patient demographics
  • Height and weight of the patient to determine correct dosage of injectables
  • Patient Medication Allergies
  • Treatment history including prior usage of medications pertinent to the member's diagnosis
  • Diagnosis with correct ICD-9 Code(s)
  • Any pertinent clinical history related to the request for the specific drug
  • If "Step Therapy", how long was the member on the previous step
  • If there are any extenuating circumstances about the patient surrounding the request for a specific medication, list those circumstances.

I've included a one-page Step Therapy Drug List in this memo. The complete list of Prior Auth Drug Protocol Requirements is also included. If I can assist any Health First Network Physician or office as we go through this transition, please do not hesitate to call me. Thank you.

William J. Whibbs, MD,
Medical Director

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