Wellcare's pa drug list app 123109.xls

WELLCARE OF OHIO - COVERED FAMILIES AND CHILDREN;
WellCare covers all medically-necessary prescription medicatiOns available through the tradtional Medicaid program, but may require prior authorization (PA) differently.
A Prior Authorization is required when:
- A brand name medication is requested and a generic exists.
- The requested medication quantity exceeds the plan's quantity limits.
- A medication is requested that has a step edit and first line therapy is inappropriate
- A Specialty medication is requested (most self-injectables and all infusion medications)
This list is not inclusive of all branded products that have generics on the WellCare Preferred Drug List because generic substitiution will automatically occur. Prescriptions with generic
alternatives designated to be dispensed with the branded product will require submission of a PA request and FDA Med Watch Report
- Providers: Complete a PA form found in the Provider area of the WellCare of Ohio website at
http://ohio.wellcare.com/providers/pharmacyservices.aspx?unsecuredprovider.
- Fax the form to WellCare’s Pharmacy Department at (877) 277-6892 [800.678-3184]. Our standard is to respond to requests within 24 hours.
SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE PHENYLEPHRINE HYDROCHLORIDE/BROMPHENIRAMINE MALEATE ACCU-CHEK OR FREESTYLE METER AND SUPPLIES SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN ACCU-CHEK OR FREESTYLE METER AND SUPPLIES SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE ARGININE HYDROCHLORIDE; ASCORBIC ACID; COB LC ARGININE; CYANOCOBALAMIN; FOLIC ACID; PIPER NLC SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN HPV BIVALENT (TYPES 16 & 18) RECOMB VAC SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN AMYLASE (DIASTASE); LIPASE (AS PANCRELIPASE); PROTEASELC PHENYLEPHRINE HYDROCHLORIDE/BROMPHENIRAMINE MALEATE ERYTHROMYCIN; BENZOYL PEROXIDE combination ACETAMINOPHEN/BUTALBUTIL/CAFFEINE/CODEINE Glycerin; Petrolatum; Phenylephrine; Shark Liver Oil Glycerin; Petrolatum; Phenylephrine; Shark Liver Oil Glycerin; Petrolatum; Phenylephrine; Shark Liver Oil INSULIN LISPRO; INSULIN LISPRO PROTAMINE (NPL) INSULIN LISPRO; INSULIN LISPRO PROTAMINE (NPL) INSULIN HUMAN (REGULAR); INSULIN HUMAN, ISOPHANE (NPHLC INSULIN HUMAN (REGULAR); INSULIN HUMAN, ISOPHANE (NPHLC SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE METFORMIN HYDROCHLORIDE; SITAGLIPTIN PHOS LC AMYLASE (DIASTASE); LIPASE (AS PANCRELIPASE); PROTEASELC DEXTROMETHORPHAN/CHLORPHENERIMINE/PHENYLEPHRINE SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN PHENYLEPHRINE HYDROCHLORIDE/BROMPHENIRAMINE MALEATE SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN ACCU-CHEK OR FREESTYLE METER AND SUPPLIES AMYLASE (DIASTASE); LIPASE (AS PANCRELIPASE); PROTEASELC ACETAMINOPHEN; CAFFEINE; DIHYDROCODEINE BITARTRATE ACETAMINOPHEN; CAFFEINE; DIHYDROCODEINE BITARTRATE AMYLASE (DIASTASE); LIPASE (AS PANCRELIPASE); PROTEASELC SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN ACCU-CHEK OR FREESTYLE METER AND SUPPLIES OMEPRAZOLE, AMOXICILLIN, CLARITHROMYCIN IR ACCU-CHEK OR FREESTYLE METER AND SUPPLIES PRECISION XTRA BLOOD GLUCOSE TEST STRIPS CHLORPHENIRAMINE/DEXTROMETHORPHAN/PHENYLEPHRINELC DEXTROMETHORPHAN/CHLORPHENERIMINE/PHENYLEPHRINE SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN NALOXONE HYDROCHLORIDE; PENTAZOCINE HYDROCHLORIDE SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN SODIUM SULFACETAMIDE-SULFFUR WASH W/MERATAN ACETAMINOPHEN; CAFFEINE; DIHYDROCODEINE BITARTRATE AMLODIPINE BESYLATE/BENAZEPRIL HYDROCHLORIDE AMLODIPINE BESYLATE/BENAZEPRIL HYDROCHLORIDE BUTYLATED HYDROXYTOLUENE (BHT); ISOBUTANE; PPG-12-BULC ACCU-CHEK OR FREESTYLE METER AND SUPPLIES AMYLASE (DIASTASE); LIPASE (AS PANCRELIPASE); PROTEASELC HYOSCYAMINE SULFATE; METHENAMINE; METHYLENE BLUE; PLC SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE

Source: https://ohio.wellcare.com/WCAssets/ohio/assets/OH_CAID_Q4_2009_PA.pdf