Verify drug authorizations
Drug authorizations
To receive approval for drugs managed under Wellmark's pharmacy programs, Wellmark encourages providers to verify membership and review the drug authorization list to see Wellmark's drug policies. If a drug is not listed, Wellmark does not maintain a policy for it. Some benefit plans have a tiered design. Review the Wellmark Drug Lists below to see what drugs are covered based on the member's benefits.
Providers are also encouraged to contact Wellmark customer service to verify benefits as some plans have medication/service exclusions not shown in the drug list.
By phone: 1-800-600-8065 and choose option 1, Monday - Friday: 7 a.m. to 7 p.m., Saturday & Sunday: 8 a.m. to 5 p.m.
Request approval
Some medications require approval before coverage.
Not sure which request applies?
- On the formulary, but requires approval = prior authorization (PA)
- Brand drug when a generic alternative is available = brand penalty waiver (BPW)
- Not on the formulary = formulary exception request (FER)
If your patient needs a nonformulary drug, you or your patient may ask for a Formulary Exception Request (FER).
To be considered for an exception request review, clinical justification must be submitted and include the following:
- All covered formulary drugs on any tier have been ineffective; or
- All covered formulary drugs on any tier will be ineffective; or
- All covered formulary drugs on any tier would not be as effective as the non-formulary drug; or
- All covered formulary drugs would have adverse effects
To complete this process, please visit the CVS Caremark® Prior Authorization page and complete the Global Prior Authorization Form. Your patient also has the option of contacting Wellmark Customer Service at the number printed on the back of his or her ID card.
Note: Administration and clinical criteria apply. Response timelines may vary based on request type, member plan, including Quality Health Plan requirements and urgency. Members and providers are notified, by mail, of the decision.
The Pharmacy Appeals Process
If a request is denied; members have the right to request further review depending on eligibility and applicable requirements. To begin the appeals process, complete the Pharmacy Appeal Form (IA and SD members).
An internal appeal may be requested following a denial of:
- Prior authorization (PA)
- Formulary exception request (FER)
- Brand penalty waiver (BPW)
Internal appeals must be submitted within 180 days of the denial notice
An external review may be available after the internal appeal process, depending on:
- Member eligibility
- Applicable state and federal requirements
External review requests must be submitted within 120 days of the first internal appeal determination if eligible.
Important: All FERs go to CVS for external review; however, some external review PAs go to CVS while others go to the state insurance division. It is important to read the appeal rights in the member denial letter carefully.
Access the state insurance division:
Wellmark, in conjunction with pharmacy benefit manager CVS Caremark®, administers a utilization management (UM) program to encourage clinically appropriate use for patients. This program is intended to minimize quantities of opioids dispensed for acute (short-term) pain needs and is based on morphine milligram equivalents, or MME. This program is designed to avoid impacting members with sickle cell disease, cancer or those under palliative care.
These prescribing limitations are consistent with guidelines issued by the Centers for Disease Control and Prevention (CDC) and National Governor’s Association Opioid Briefing.
Limit to a 7-day supply
When appropriate, the length of the first prescription fill will be limited to seven days for new, acute opioid prescriptions for members who do not have a history of prior opioid use (based on their prescription claims).
A physician can submit a prior authorization (PA) request if it is important to exceed the seven-day fill limit.
The quantity of opioid products prescribed — including those that are combined with acetaminophen (APAP), ibuprofen or aspirin (ASA) — will initially be limited to ensure amount does not exceed the maximum daily dose listed in labeling. Quantities are also ≤ 90 MME per day and contain ≤ 4 g APAP or ASA and ≤ 3200 mg ibuprofen.
Prescribers who believe a patient should exceed CDC guideline recommendations can submit a PA request for up to 200 MME per day. Quantities higher than that would require an appeal.
Note: Quantity limits will not apply to patients with cancer, a terminal condition or pain being managed through hospice or palliative care.
Use of an immediate-release (IR) formulation will be required before moving to an extended-release (ER) formulation, unless the member has a previous claim for an IR or ER product, or the prescriber submits a PA request.
Select the policy below for more information.
Disclosures
CVS Caremark® is a registered trademark of CVS Health Corp., an independent company that provides pharmacy services on behalf of Wellmark Blue Cross and Blue Shield. This website contains references to brand-name prescription drugs that are trademarks or register trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark.