Prior Authorization, Step Therapy and Quantity Limits
Our plan has a team of doctors and pharmacists who create tools to help us provide you with quality prescription drug coverage. These tools may include prior authorization, step therapy, quantity limits and age limits.
Prescription Drug Coverage Requirements
Prior Authorization
We require you to get approval from us before we agree to cover certain drugs. We call this prior authorization. If you do not get approval, you may be asked to pay for the drug.
Drugs that require prior authorization are marked with PA or PA-NS on the List of Drugs (Formulary).
Step Therapy
In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. This requirement to try a different drug first is called step therapy.
Drugs that require step therapy are marked with ST on the List of Drugs (Formulary).
Quantity Limits
For certain drugs, we limit the amount of the drug that we will cover. For example, coverage may be limited to one tablet per day. This limit may be in addition to a standard one-month or three-month supply.
Drugs with quantity limits are marked with QL on the List of Drugs (Formulary).
Age Limits
Some drugs require prior authorization if your age does not meet the drug manufacturer’s guidelines, U.S. Food and Drug Administration (FDA) requirements or clinical recommendations.
Drug Coverage Criteria
Prior Authorization Criteria
To view the PA Criteria for your specific Wellcare By Fidelis Care plan, visit our Prescription Drug Information page and select the Prior Authorization accordion.
Step Therapy Criteria
To view the ST Criteria for your specific Wellcare By Fidelis Care plan, visit our Prescription Drug Information page and select the Step Therapy accordion.
Quantity Limits
Refer to the List of Drugs (Formulary) for drug-specific coverage requirements and quantity limits.
Drug Coverage Determinations
You can ask us to make an exception to our prescription drug coverage rules. To learn about the types of exceptions you may request, refer to your Evidence of Coverage on our Medicare Resources page.
When requesting an exception, include a statement from your doctor explaining why the drug is medically necessary, along with a completed Drug Coverage Determination Request Form.
Generally, we must make a decision within 72 hours after we receive your doctor’s supporting statement. You or your doctor can request a fast, or expedited, exception if waiting for a standard decision could harm your health.
If we approve your request for an expedited decision, we must provide a decision within 24 hours after we receive your doctor’s supporting statement.
For more information about requesting an exception or appealing a drug coverage decision, visit our Coverage Determinations and Redeterminations for Drugs page.
Prescription Drug Claim Forms
If you need to request reimbursement for a prescription drug you paid for out of pocket, complete the applicable Prescription Drug Claim Form below.
Prescription Drug Claim Form - English (PDF)
Prescription Drug Claim Form - Spanish (PDF)
Contact Member Services
If you have questions or need the most recent List of Drugs, call Member Services at 1-800-247-1447 (TTY: 711). We are here to help.