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Step Therapy programs are developed by Wellcare's P&T Committee. They encourage the use of therapeutically equivalent, lower-cost medication alternatives (first-line therapy) before “stepping up” to alternatives that are usually less cost-effective.

Step Therapy programs are intended to be a safe and effective method of reducing the cost of treatment by ensuring that an adequate trial of a proven safe and cost-effective therapy is attempted before progressing to a more costly option. First-line drugs are recognized as safe, effective, and economically sound treatments.

The first-line drugs on Wellcare’s formulary have been evaluated through the use of clinical literature and are approved by Wellcare’s P&T Committee. Step therapy is failure of at least one different or less expensive drug prior to coverage of a drug on this list. 

Drugs requiring step therapy effective January 01, 2024 are listed below. The prescriber, patient, or authorized representative may ask for an exception. Step therapy applies if the drug has not been used in the past 365 days.

Drug Name                                                       

Abatacept (Orencia®)

Ado-trastuzumab emtansine (Kadcyla®)

Aflibercept (Eylea®)

Atezolizumab (Tecentriq®)

Axicabtagene ciloleucel (Yescarta®)

Bevacizumab (Avastin®, Alymsys®, Mvasi®, Vegzelma, Zirabev)

Brentuximab vedotin (Adcetris®)

Brexucabtagene autoleucel (Tecartus)

Brolucizumab-dbll (Beovu®)

Cemiplimab-rwlc (Libtayo®)

Certolizumab (Cimzia®)

Ciltacabtagene autoleucel (Carvykti)

Corticosteroid intravitreal implants: dexamethasone (Ozurdex®), fluocinolone acetonide (Iluvien®, Retisert®, Yutiq)

Corticotropin (H.P. Acthar®, Purified Cortrophin Gel)

Daratumumab (Darzalex®), daratumumab/hyaluronidase-fihj (Darzalex Faspro)

Darbepoetin alfa (Aranesp®)

Denosumab (Xgeva®)

Durvalumab (Imfinzi®)

Eflapegrastim-xnst (Rolvedon)

Elotuzumab (Empliciti®)

Emapalumab-lzsg (Gamifant)

Epoetin alfa (Epogen®, Procrit®)

Faricimab-svoa (Vabysmo)

Ferric carboxymaltose (Injectafer®)

Ferric derisomaltose (Monoferric®)

Ferric pyrophosphate (Triferic®, Triferic Avnu®)

Ferumoxytol (Feraheme®)

Filgrastim (Neupogen®, Zarxio®, Nivestym, Granix®, Releuko®)

Golimumab (Simponi®, Simponi Aria®)

Hyaluronate derivatives: sodium hyaluronate (Euflexxa®, Gelsyn-3, GenVisc®850, Hyalgan®, Supartz FX, Synojoynt, Triluron, TriVisc, VISCO-3), hyaluronic acid (Durolane®), cross-linked hyaluronate (Gel-One®), hyaluronan (Hymovis®, Orthovisc®, Monovisc®), hylan polymers A and B (Synvisc®, Synvisc One®)

Idecabtagene vicleucel (Abecma)

Immune globulins (Asceniv, Bivigamâ, Cutaquigâ, Cuvitru, Flebogammaâ DIF, GamaSTANâ, GamaSTANâ S/D, Gammagardâ liquid, Gammagardâ S/D, Gammaked, Gammaplexâ, Gamunexâ-C, Hizentra®, HyQviaâ, Octagamâ, Panzygaâ, Privigenâ, Xembifyâ)

IncobotulinumtoxinA (Xeomin®)

Lisocabtagene maraleucel (Breyanzi®)

Lurbinectedin (Zepzelca)

Luspatercept-aamt (Reblozyl®)

Lutetium Lu 177 dotatate (Lutathera®)

Nadofaragene firadenovec-vncg (Adstiladrin®)

Natalizumab (Tysabri®)

Nivolumab (Opdivo®)

Pegfilgrastim (Neulasta®, Fulphila, Fylnetra®, Nyvepria, Stimufend®, Udenyca, Ziextenzo)

Pembrolizumab (Keytruda®)

Polatuzumab vedotin-piiq (Polivy)

Ramucirumab (Cyramza®)

Ranibizumab (Lucentis®, Byooviz®, Cimerli, Susvimo)

RimabotulinumtoxinB (Myobloc®)

Rituximab (Rituxan®, Riabni, Ruxience, Truxima®), rituximab/hyaluronidase (Rituxan Hycela)

Romiplostim (Nplate®)

Romosuzumab-aqqg (Evenity)

Sargramostim (Leukine®)

Sipuleucel-T (Provenge®)

Teclistamab-cqyv (Tecvayli®)

Teprotumumab-trbw (Tepezza)

Tisagenlecleucel (Kymriah®)

Tocilizumab (Actemra®)

Trastuzumab (Herceptin®, Ontruzant®, Herzuma®, Ogivri, Trazimera, Kanjinti), trastuzumab/hyaluronidase (Herceptin Hylecta)

Triamcinolone ER injection (Zilretta®)

Triamcinolone acetonide suprachoroidal injection (Xipere)

Vedolizumab (Entyvio®)

Verteporfin (Visudyne®)

 

Medicare Prior Authorization

List effective 10/1/2023

Wellcare Oklahoma requires prior authorization (PA) as a condition of payment for many services.  This Notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Wellcare.

Wellcare is committed to delivering cost effective quality care to our members.  This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice.  Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.

It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.

 

Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.       

For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool on our website at WellcareOK.com.

 

Effective October 1st, 2023, the following are changes to prior authorization requirements

 

 

Service Category

 

PA Rule

Services

Procedure Codes

Audiology

No PA Required

Pure tone audiometry 

0208T, 0209T

Behavioral Health

No PA Required

Alcohol and/or drug services

H0010, H0011, H0012, H0014, H0016, H0018

Assertive community treatment, face-to-face

H0039

BH and Community Support Services

H2001, H2012, H2016, H2018, H2020, H2022, H2030, H2034, H2036

Crisis intervention mental health services, per hour

S9484, S9485

Adaptive behavior treatment

97157

Breast Reconstruction

No PA Required

Repair and/or reconstruction

19357, 19367, 19368, S2068

Cardiovascular

PA Required

Coronary intravascular lithotripsy (IVL) procedure

0715T

Pacemaker/cardioverter-defibrillator devices and procedures

C1899, G0448

No PA Required

Device interrogation and analysis

0418T

Transcatheter valve and cardiac procedures

0483T, 0569T, 0644T

DME & Supplies

PA Required

Hospital bed and mattress

E0302, E0372, E0462

Respiratory systems and supplies

E0440, E0467

Patient lifts

E0639

Pneumatic & non-pneumatic compressor devices

E0657, E0665, E0666, E0669, E0670, E0672, K1024, K1033

Ultraviolet light therapy

E0691, E0694

Wheelchairs, power operated vehicles, and accessories

E0983, E0985, E0988, E1004, E1036, E1070, E1084, E1087, E1170, E1222, E1223, E1228, E1239, E1270, E1280, E1296, E1298, E2328, E2341, E2343, E2358, E2362, E2364, E2368, E2369, E2610, E2614, E2625, E2631, E2632, E2633, K0008, K0009, K0011, K0012, K0014, K0015, K0046, K0065, K0098, K0669, K0802, K0807, K0812, K0814, K0815, K0829, K0850, K0851, K0852, K0853, K0860, K0864, K0877, K0878, K0884, K0891, K0898, K0899

Nerve stimulating device

K1018

Speech generating device/accessory

E2502

Automatic external defibrillator

K0606

No PA Required

Compression burn garment

A6507

Hospital bed, mattress, and supplies

E0181, E0182, E0189, E0305, E0310, E0316, E0328

Electronic bowel irrigation system

E0350

Delivery/installation charges for hemodialysis equipment

E1600

Heat, cold, and light therapies

E0202, E0217, E0221

Respiratory systems, devices and supplies

A7047, E0435, E0455, E0472, E0500

Breast pump, hospital grade, electric

E0604

Monitoring equipment

E0619, E0620

Functional electrical stimulator

E0770

Traction and other orthopedic devices

E0856, E0944

 

 

 

 

Wheelchairs and accessories

E0968, E0969, E0980, E0994, E1014, E1029, E1092, E1093, E1160, E1229, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E2291, E2292, E2293, E2294, E2301, E2324, E2381, E2382, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, K0017, K0018, K0020, K0053, K0105, K0195

Blood glucose monitor

E2100, E2102

Evaluation & Management

No PA Required

Nursing facility care plan oversight

99306, 99379

Medication therapy management

99605, 99606, 99607

General Surgery

PA Required

Repair procedures on the nose

30410, 30420, 30430, 30520

Procedures on the stomach

43881 

Procedures on the penis

54400, 54401, 54405

Phrenic nerve stimulation system procedure

0435T

Benign thyroid nodule ablation

0673T

No PA Required, unless managed by a vendor in select markets

Removal of abdominal mesh

11008

Removal of skin tags procedures

11200, 11201

Skin color correction

11920, 11921, 11922

Tissue expanders

11960, 11970, 11971 

Skin therapies

15786, 15787, 17360

Trigger point injections

20552, 20553

Cranial/facial repairs

21175, 21181, 21183, 21193, 21230, 21256, 21280

Repair procedures on the nose

30460, 30462, 30560, 30630

 

Transplant related procedures

32855, 32856, 33933, 33940, 33944, 38206, 38207, 38208, 38209, 38214, 38215, 38230, 47143, 48551, 48552, 50300, 50320, 50323, 50325, 50327, 50328, 50329, 50370

Repair procedures on the urethra

52010, 52301, 52343, 53420

Excision procedures on the endocrine system

60212, 60505

Procedures on the spine/spinal cord

22527, 62367, 62368, 62370

Procedures on the cardiovascular system

33952, 36836, 36837

Procedures on the spleen

38129

Procedures on the diaphragm

39599

Procedures on the digestive system

43283, 43772, 43774, 44145, 64595

Neurostimulator procedures on the peripheral nerves

64585

GI Services

No PA Required

Transnasal EGD

0652T, 0653T

Gynecology

No PA Required

Excision/repair of the vulva, vagina

56625, 57291, 57292

Hysterectomy procedures

58150, 58152, 58180, 58200, 58210, 58240, 58260, 58262, 58263, 58270, 58275, 58280, 58290, 58291, 58292, 58541, 58542, 58543, 58544, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58575, 58951, 58953, 58954, 58956

Myomectomy, ovarian/tubal resection

58545, 58546, 58661, 58720, 58940, 58952

Home Care

No PA Required

Home care services

S5145, S5150

Contracted home health

T1022

Injection Procedures

PA Required

Percutaneous lumbar intravertebral disc injection

0627T, 0628T

No PA Required

Injection of the spine/spinal cord

62280, 62290, 62291, 62324, 62325, 62326, 62327

Maternity

No PA Required

Maternity care

59866, 59897

Medicine Services & Procedures

No PA Required, unless managed by a vendor in select markets

Instillation, bupivacaine and meloxicam, 1 mg/0.03 mg

C9088

Immune globulins, serum or recombinant product

90283

Special otorhinolaryngologic procedures

92512, 92516, 92520, 92546, 92597, 92607, 92608, 92609, 92610, 92700

Neurology testing

95700, 95803

Chiropractic treatment

98940, 98941, 98942

Education and training for patient self-management

98960

Nutrition

No PA Required

Medical nutrition therapy

97804

Enteral formulas and additives

B4157, B4158, B4159, B4162, B9006

Medical foods for inborn errors of metabolism

S9435

Orthopedics

PA Required

Insertion sinus tarsi implant

0335T

Sacroiliac joint arthrodesis procedure

0775T

Ophthalmology

No PA Required

Open–eye eyelid treatment device 

0563T

Other procedures on the cornea

65765

Orthotics and Prosthetics

PA Required

Spinal orthotics

L0458, L0468, L0480, L0484, L0632, L0638, L0639, L0640, L0651, L1200, L1300

Lower extremity orthotics

E1830, L1690, L1840, L1904, L2000, L2005, L2030, L2034, L2038, L2525, L2627, L2628

Upper extremity orthotics

E1802, E1818, E1840

Lower extremity prosthetics

K1014, L5010, L5060, L5200, L5505, L5510, L5520, L5535, L5560, L5570, L5600, L5610, L5614, L5628, L5630, L5638, L5639, L5640, L5661, L5682, L5702, L5795, L5818, L5824, L5826, L5830, L5858, L5859, L5930, L5966, L5969, L5982, L5990

Upper extremity prosthetics

L6000, L6010, L6020, L6200, L6250, L6320, L6400, L6623, L6628, L6638, L6646, L6647, L6692, L6697, L6704, L6711, L6712, L6883, L6885, L6895, L6900, L6905, L6910, L6920, L6925, L6940, L6945, L6950, L6965, L7405

Cochlear device

L8614

Orbital prosthetics

L8042

Unlisted prosthetics

L8499

No PA Required

Penile devices

C2622, L7900

Spinal orthotics

L0700, L0710

Upper extremity orthotics

L0170, L0190, L3671, L3674, L3962

Lower extremity orthotics

L0469, L0470, L1000, L1270, L1640, L1730, L1847, L1860, L2126, L2136, L2570, L2580

Cochlear implant device components

L8627, L8628, L8629

Pretibial shell

L4130

Prosthetic fitting, immediate post-surgical

L5400, L5420, L5430

Nasal and facial prosthesis

L8040, L8046, V2629

Finger prosthetics

L8659

Pain Management

PA Required

Percutaneous cranial nerves stimulation

0720T

Injection of anesthetic agent (nerve block)

64450, 64451, 64494

Destruction by neurolytic agent

64624

Pathology and Laboratory

PA Required

Genetic analysis  

81265, 81266

No PA Required

Multianalyte assays

0014M

Proprietary laboratory analyses

0035U, 0040U, 0219U, 0353U

Therapeutic drug assays

80220

Genetic analysis  

81224, 81239, 81262, 81316, 81341

Multianalyte assays w/algorithmic analyses

81508, 81511, 81512, 81513, 81514, 81528

Chemistry procedures

82077, 82105, 82397, 82657, 82677, 84163, 84702, 84704, 84999

Qualitative or semiquantitative immunoassays

86152, 86336

Postmortem examination

88025

Flow cytometry, cytogenetic studies

88182, 88230, 88233, 88235, 88237, 88263, 88269, 88291

Surgical pathology

88364, 88365, 88366, 88367, 88368, 88369, 88373, 88374, 88377, 88381

Reproductive medicine

89310, 89320, 89321

Pharmacy

No PA Required

Pharmacy dispensing fee for inhalation drug(s)

Q0513, Q0514

Pharmacy compounding and dispensing services

S9430

Professional Services

No PA Required

Molecular pathology procedure; physician interpretation and report

G0452

Hospital observation service and admission

G0378, G0379

Radiology Services

No PA Required – except when managed by vendor in select markets

PET imaging, any site, NOS

G0235

ERCP with endomicroscopy

0397T

Quantitative ultrasound tissue characterization

0690T

Fetal MRI

74713

Endocrine system

78012, 78013, 78014, 78018, 78070, 78071, 78072

Bone marrow imaging

78102

Gastrointestinal system

78201, 78202, 78215, 78216, 78226, 78227

Cardiovascular system

75565, 78434

Radiopharmaceutical localization of tumor

78800, 78804

Radiopharmaceuticals

PA Required

Lutetium lu 177 vipivotide tetraxetan, therapeutic

A9607

No PA Required

Radiopharmaceutical, diagnostic, not otherwise classified

A4641

Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose

A9552

Rubidium Rb-82, diagnostic, per study dose

A9555

Skin Substitute

PA Required

Skin substitute products

Q4199

No PA Required

Autograft suspension

C1832

Specialty Medications                                                                 

PA Required

Injectable Medication

J1950, J2182, J2786, J9214, J9044

Intravitreal implant

J7313

Hyaluronic injections

J7322, J7328

No PA Required

Inhalation medications

J7605, J7606, J7626

Injectables

J0121, J0572, J0573, J0574, J1750, J1756, J2212, J2440, J1453, J3489, S0039, S0080

Other medication

S0091, S0157

Therapy Services

No PA Required, unless managed by a vendor in select markets

Physical medicine and rehab evaluations

97164, 97168, 97169, 97170, 97172, 97750

Occupational therapy services, qualified occupational therapist

G0129

Speech, language, dysphagia screenings

V5362, V5363, V5364

Electrical stimulation, (unattended)

G0281, G0282

Wound Care

PA Required

Active wound care management – PA required after 12 combined wound care visits per calendar year

97597, 97598, 97602

Electrical stimulation and cutaneous wound healing

0512T

Matrix for wound management

A2001, A2002, A2004, A2005, A2007, A2015

 

Who is Express Scripts?

Express Scripts is a pharmacy benefit management (PBM) company serving more than 100 million Americans. Express Scripts Pharmacy delivers specialized care that puts patients first through a smarter approach to pharmacy services.

What is the rationale for changing PBM vendors?

Express Scripts as our PBM will bring increased levels of transparency and value, positioning us to provide the highest level of quality at the lowest possible cost to our members.

What PBM services will Express Scripts be providing?

Express Scripts will be the PBM of record providing pharmacy claims adjudication, pharmacy network administration and rebate administration on behalf of our health plan.

How will this PBM transition impact our members?

There will be no immediate change in service for our members, although they will receive new ID cards. We will continue to provide the same member-focused care and support as we do today.

Our highest priority continues to be serving all our members, and we remain committed to providing affordable quality healthcare services. Our team is working closely with both CVS and Express Scripts to ensure a seamless migration.

Is Amazon part of the Express Scripts Network?

Yes, Amazon is part of the Express Scripts network.

Can members still use CVS Caremark for their mail orders?

No, CVS Caremark Mail Service Pharmacy will be out of network, effective January 1, 2024. If members wish to continue using mail order in 2024, they must switch to Express Scripts Pharmacy.

Do members have a choice besides Express Scripts for mail order services?

Members have a choice to use other pharmacies that offer home delivery but Epress Scripts Pharmacy is the preferred mail order pharmacy for our health plan.

Are we communicating this mail order change to members?

Yes. Impacted Medicaid members will receive a Mail Order Change notification letter.

How will members get started with mail order at Express Scripts?

For existing mail order users:

  • Most open prescription refills will be automatically transferred to Express Scripts
  • Refills for controlled drugs, such as Alprazolam, Clonazepam, Pregabalin, Tramadol, Zolpidem, etc., will not automatically transfer to Express Scripts Pharmacy; members must request a new prescription from their provider

For new mail order prescriptions on or after January 1, 2024, members may do one of the following:

  • Ask their provider to electronically submit or fax a new prescription to Express Scripts Pharmacy, as listed on their medical ID cards
  • Visit express-scripts.com/rx to register or sign in, then follow the guided steps to request a prescription
  • Call Express Scripts Pharmacy, who will contact their provider for a new prescription to be filled via mail order
  • Mail a Home Delivery Order Form (available at express-scripts.com/rx) directly to Express Scripts Pharmacy

Does Express Scripts offer a mail order app?

Yes, members will be able to download the Express Scripts Pharmacy app, available on the App Store and Google Play. Members with a mail order benefit can order medications, track delivery and more.

 

 

PRO_ 2435207_E_Internal Approved 10102023                                                  

We are pleased to announce that, effective January 1, 2024, Express Scripts® will begin processing pharmacy claims for our plan members.

Express Scripts is a pharmacy benefit management (PBM) company serving more than 100 million Americans. Express Scripts Pharmacy delivers specialized care that puts patients first through a smarter approach to pharmacy services.

Members have been notified in advance and will receive a new ID card with updated pharmacy information, so that they are prepared to begin having their prescriptions filled at participating network pharmacies when this change occurs.

Providers can direct members to call the Member Services phone number listed on their ID card should they have questions about this change.

Please contact your Provider Relations Representative with any additional questions.

Thank you for the care you provide to our members.

 

 

 

PRO_2433922E_State/Internal Approved 09272023