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Prior Authorization and Quantity Limits

Some drugs, and certain amounts of some drugs, require an approval before they can be covered by your patients' benefits. This process is called prior authorization.

  • Drugs indicated as non-formulary cannot be approved through the prior authorization process.
  • The prescribing provider should contact Wellmark’s Clinical Call Center at 800-600-8065 or refer to the CVS/caremark Prior Authorization Information page to download the Global Prior Authorization Form pdf and fax to 866-249-6155 to request approval for specialty drugs requiring prior authorization. Obtaining the approval in advance will help to prevent delays at the pharmacy.
  • If the drug is approved, the prescription can be filled at any in-network pharmacy.

Your patient can log in to myWellmark to check his or her benefits to see if a drug is covered.

 

Most prescription drugs are limited to a maximum quantity in a single prescription. Federal regulations limit the quantity that may be dispensed for certain medications. If your prescription is so regulated, it may not be available in the amount prescribed by your health care provider.


In addition, coverage for certain drugs is limited to specific quantities per month, benefit year, or lifetime. Amounts in excess of quantity limitations are not covered unless there is prior authorization criteria in place to request additional quantities and approval is granted.

 

Your patient's benefits certificate, coverage manual, or policy has specific information about his or her plan's prior authorization requirements.

 

Click on the drug name below for more detailed information regarding our policy.

 

All Opioid-related drugs 

Searching for a specific drug? If you are using a PC, press ‘CTRL’ and ‘F’ on your keyboard at the same time to search for a drug by name. If you are using a Mac, press ‘Command’ and ‘F’ on your keyboard at the same time.

 

Abstral
Acanya
Aciphex Sprinkles
Actemra
Acticlate
Actiq
Aczone
Adapalene 0.3%
Adcirca
Adderall XR
Adempas
Admelog
Adoxa
Adzensys XR-ODT
Aerospan
Afrezza
AirDuo RespiClick (BRAND ONLY)
Alsuma
Alvesco
Amphetamine-Dextroamphetamine ER
Androderm
Androgel
Androgel Pump
Apidra
Aptensio XR
Aralast NP
Armodafanil
Atralin
Aubagio
Avita
Avonex
Axiron
Banzel 
Basaglar
Beconase AQ
Belsomra
Benzaclin
Benzoyl Peroxide/Clindamycin
Berinert
Betaseron
Bivigam
Botox
Carac Cream
Carimune NF
Cerdelga

Cerezyme
Cimzia
Cinryze
Cinqair
Clindamycin Foam
Compounded Drug Products
Concerta
Condylox Gel
Copaxone
Cosentyx
Cotempla XR
Cuvitru
Cystic Fibrosis
Daklinza
Daytrana
Desvenlafaxine ER
Desvenlafaxine Fumarate ER
Dexedrine
Dexilant
Dexmethylphenidate ER
Dextroamphetamine ER
Differin 0.3%
Doryx
Doxycycline delayed release
Duac
Dupixent
Dyanavel XR
Dymista
Dysport
Edluar
Elelyso
Emflaza
Enbrel
Entresto
Entyvio
Epclusa
Epiduo Forte
Epoprostenol
Esbriet
Esomeprazole Strontium
Euflexxa
Evekeo
Evoclin
Extavia
Farxiga
Fasenra
Fentanyl Lozenge
Fentora
Fetzima
Firazyr
Flebogamma
Flolan
Flovent
Flunisolide Nasal Solution
Fluoroplex
Fluorouracil 0.5% Cream
Fluvoxamine Maleate ER
Focalin XR
Fortesta
Frova
Frovatriptan
Gammagard
Gammaked
Gammaplex
Gamunex C
Gel-One
Gelsyn-3
Genotropin
Genvisc 850
Gilenya
Glassia
Glatopa
Glucose Test Strips

Granix
Grastek
H.P. Acthar
Harvoni
Haegarda
Hetlioz
Hizentra
Humalog
Humalog Mix 50/50
Humalog Mix 75/25
Humatrope
Humira
Humulin 70/30
Humulin N
Humulin R-100
Hyalgan
Hymovis
Hyqvia
Inflectra
Ingrezza
Intermezzo
Itraconazole
Jublia
Juxtapid
Kalbitor
Kalydeco
Kerydin
Kevzara
Khedezla
Kineret
Kombiglyze ER
Kynamro
Lemtrada
Letairis

Leukine
Levemir
Luvox CR
Luxturna
Mavyret
Metadate CD
Metadate ER
Methylphenidate CD
Methylphenidate ER
Minocycline ER
Mirapex ER
Modafinil
Mometasone Nasal Spray
Monovisc
Movantik
Mydayis
Myobloc
Nasonex
Natesto
Neuac

Neupogen
Nexium Capsules
Nexium Packets
Norditropin
Nucala
Nutropin
Nutropin AQ
Nuvigil
Ocaliva
Ocrevus
Octagam
Odactra
Ofev
Olysio
Omnaris
Omnitrope
Onexton
Onfi
Onglyza
Onmel
Onsolis
Opsumit
Oracea
Oralair
Orencia
Orenitram
Orthovisc
Orkambi
Otezla
Pegasys
Pexeva
Picato
Plegridy
Pradaxa
Praluent
Prevacid Solutabs
Prilosec Packets
Pristiq
Privigen
Prolastin-C
Protonix Packets
Provigil
Pulmicort Flexhaler
Qnasl
Qnasl Child
Qtern
QuilliChew ER
Quillivant XR
Radicava
Ragwitek
Raloxifene
Ravicti
Rebif
Relistor
Relpax
Remicade
Remodulin
Renflexis
Repatha
Requip XL
Retin A Micro
Retin-A
Revatio
Rexulti
Ritalin LA
Rituxan
Rituxan Hycela
Ropinirole ER
Rozerem
Ruconest
Saizen
Sandostatin LAR
Savaysa
Segluromet
Serostim
Signifor LAR
Sildenafil
Silenor

Siliq
Simponi
Simponi Aria
Solodyn

Sovaldi
Spinraza
Sporanox
Steglatro
Stelara
Strensiq
Striant
Subsys
Sumavel Dosepro
Supartz
Symbicort
Synagis
Synvisc
Synvisc-One
Taltz
Tamoxifen
Tanzeum
Targadox
Tecfidera
Technivie
Testim
Testosterone Gel 1%
Testosterone Gel Pump 1% 
Tolak
Tracleer

Tremfya
Tresiba
Tretinoin Micronized topical
Tretinoin topical
Treximet
Trintellix
Trulicity
Tysabri
Tyvaso
Uptravi
Veletri
Veltin
Ventavis
Veramyst
Veregen Ointment
Viekira Pak
Viekira XR
Viibryd
Visco-3
Vogelxo
Vosevi
VPRIV
Vraylar
Vyvanse
Xeljanz
Xeljanz XR
Xeomin
Xermelo
Xigduo XR
Ximino
Xolair
Xyrem
Yervoy
Zavesca
Zecuity
Zemaira
Zepatier
Zetonna
Ziana
Zolpimist
Zomacton
Zomig Nasal Spray
Zorbtive
Zyclara


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