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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.

Sincerely,
William J. Whibbs, MD,
Medical Director

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