To receive approval for drugs managed under Wellmark's pharmacy programs:
- Use the drug authorization list to determine if the authorization is needed.
- Log in to submit the drug authorization Secure Site request.
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.
Pharmacy resources your patients need
Formulary drug lists
Some benefit plans have a tiered design. Search the Wellmark Drug List to see what drugs are covered based on the member’s plan benefits.
Formulary exception process
Prior to purchasing a non-formulary drug, you may ask for a formulary exception request through the submission of a formulary exception request.
Mail order pharmacy service
Depending on a member’s benefits, they may be able to save time and money by using mail order pharmacy for the prescriptions they take regularly. Learn more about mail order pharmacy service.
Learn about the waiver of brand penalty
Depending on a member’s benefits, they may be charged more if they receive a brand drug when a generic is available and would be required to pay the difference if they select the brand drug. However, if there is a medical reason they must take the brand drug, we may not require them to pay the difference.
Opioid Medication Management Program
Wellmark, in conjunction with pharmacy benefit manager CVS Caremark®, is strengthening the utilization management (UM) program to encourage clinically appropriate use for patients. This program is intended to ensure smaller quantities of opioids are dispensed for acute (short-term) pain needs and is based on morphine milligram equivalents, or MME. This program is not designed to impact members with chronic pain or those undergoing care for serious illnesses.
These prescribing limitations are consistent with guidelines issued by the Centers for Disease Control and Prevention (CDC) and National Governor’s Association Opioid Briefing, and those under consideration by the Iowa legislature.
Enhanced MME-based utilization management programLimit 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.Limit quantity of opioids
The quantity of opioid products prescribed — including those that are combined with acetaminophen, ibuprofen or aspirin — will initially be limited to ensure amount does not exceed the maximum daily dose listed in labeling. Quantities are also ≤ 90 MME or less 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.Require step therapy
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.
- Opioids ER - Step Therapy with MME Limit and Post Limit Policy PDF File
- Opioids IR - Acute Pain Duration Limit with MME Limit and Post Limit Policy PDF File
- Opioids IR - APAP-ASA-IBU Combo Products Acute Pain Duration Limit Policy PDF File
- Opioids IR - APAP-ASA-IBU Combo Products Limit Policy PDF File