On April 22, 2024, UnitedHealth Group issued a press release, providing an update on the Change Healthcare cybersecurity incident that occurred on Feb. 21, 2024. Given the size of the data impacted, the investigation to determine whose data is impacted is expected to take several months. UnitedHealth Group believes this situation will impact “a substantial proportion of people in America” and is offering immediate credit monitoring and identity protection services, as well as a dedicated contact center to address questions. Visit Change Healthcare Cyberattack Support and/or reach out to the contact center at 1-866-262-5342 regarding any questions.
Prior Authorization, Step Therapy & Quantity Limitations |
Prior Authorization, Step Therapy and Quantity Limits
Our plan has a team of doctors and pharmacists who create tools to help us provide you quality coverage. Examples are:
- Prior Authorization: We require you to get approval from us before we agree to cover certain drugs. We call this prior authorization. If you don’t get approval, you may be asked to pay for the drug. Drugs that require a prior authorization are noted with a “PA or PA-NS” on the List of Drugs (formulary).
- Step Therapy: In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. This requirement to try a different drug first is called step therapy. Drugs that require step therapy are noted with an “ST” on the List of Drugs (formulary).
- Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover. For example, one tablet per day. This may be in addition to a standard one-month or three-month supply. Drugs that require quantity limits are noted with “QL” on the List of Drugs (formulary).
- Age Limits: Some drugs require a prior authorization if your age does not meet drug manufacturer, Food and Drug Administration (FDA), or clinical recommendations.
Prior Authorization Criteria:
Updated October 1, 2024:
- Wellcare No Premium Open (PPO)
- Wellcare No Premium (HMO)
- Wellcare No Premium Focus (HMO)
- Imperial, San Diego, San Francisco
- Wellcare No Premium Ruby (HMO)
- Wellcare Premium Ultra (HMO)
- Wellcare Dual Liberty (HMO D-SNP)
- Wellcare Specialty No Premium (HMO C-SNP)
- Wellcare Low Premium (HMO)
- Wellcare No Premium Focus (HMO)
- Los Angeles, Orange, Riverside, San Bernardino
- Wellcare CalViva Health Dual Align (HMO D-SNP)
- Wellcare Dual Align (HMO D-SNP)
Step Therapy Criteria:
Updated October 15, 2023:
- Wellcare No Premium Open (PPO)
- Wellcare No Premium (HMO)
- Wellcare No Premium Focus (HMO)
- Imperial, San Diego, San Francisco
- Wellcare No Premium Ruby (HMO)
- Wellcare Premium Ultra (HMO)
- Wellcare Dual Liberty (HMO D-SNP)
- Wellcare Specialty No Premium (HMO C-SNP)
- Wellcare Low Premium (HMO)
- Wellcare No Premium Focus (HMO)
- Los Angeles, Orange, Riverside, San Bernardino
- Wellcare CalViva Health Dual Align (HMO D-SNP)
- Wellcare Dual Align (HMO D-SNP)
Quantity Limits: Refer to the List of Drugs (Formulary) for drug requirements and limits.
Drug Coverage Determinations
You can ask us to make an exception to our coverage rules. To learn about the specific types of exceptions, refer to your Evidence of Coverage . When asking for an exception, include a statement from your doctor that supports your request, plus a completed Coverage Determination form.
Generally, we must decide within 72 hours of getting your doctor’s supporting statement. You or your doctor can request a fast (expedited) exception if your health may be harmed by waiting. If we approve your expedited request, we must give you a decision within 24 hours after we get your doctor’s supporting statement.
Refer to the Coverage Determinations and Redeterminations page for more information.
“If you have questions or want to get the most recent list of drugs, contact Member Services. We are here to help.”
If you have questions or want to get the most recent list of drugs, contact Member Services. We are here to help.