Medicare Prior Authorization
Date: 05/16/23
Wellcare 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 the Online Prior Authorization Tool on our website
Effective July 1st, 2023, the following are changes to prior authorization requirements:
Service Category |
PA Rule | Services | Procedure Codes |
|---|---|---|---|
Observation | No PA Required | Observation services | Rev code: 762 |
Surgical procedures | No PA Required | Subcutaneous hormone pellet implantation | 11980 |
Injectable medications | Step therapy | Injectables | J0587, J0588, J1437, J1439, J1443, J1444, J1445, J1449, J1460, J1560, Q0138, Q0139, Q5126, Q5127, Q5128, Q5129, Q5130 |
PA Required - No Step Therapy | Injection, onabotulinumotxinA, 1 unit | J0585 | |
No PA Required | Injectables | J0897, J1750, J1756, J2916, Q0221 |
Part B Drug List Updates Effective July 1, 2023
The following drugs require utilization review.
| PROCEDURE | DESCRIPTION | STEP THERAPY |
|---|---|---|
| J0585 | INJECTION, ONABOTULINUMOTXINA, 1 UNIT | |
| J0587 | INJECTION, RIMABOTULINUMTOXINB, 100 UNITS | STEP THERAPY |
| J0588 | INJECTION, INCOBOTULINUMTOXIN A, 1 UNIT | STEP THERAPY |
| J1437 | INJECTION, FERRIC DERISOMALTOSE, 10 MG | STEP THERAPY |
| J1439 | INJECTION, FERRIC CARBOXYMALTOSE, 1 MG | STEP THERAPY |
| J1443 | INJECTION, FERRIC PYROPHOSPHATE CITRATE SOLUTION (TRIFERIC), 0.1 MG OF IRON | STEP THERAPY |
| J1444 | INJECTION, FERRIC PYROPHOSPHATE CITRATE POWDER, 0.1 MG OF IRON | STEP THERAPY |
| J1445 | INJECTION, FERRIC PYROPHOSPHATE CITRATE SOLUTION (TRIFERIC AVNU), 0.1 MG OF IRON | STEP THERAPY |
| J1449 | INJECTION, EFLAPEGRASTIM-XNST (ROLVEDON), 0.1 MG | STEP THERAPY |
| J1460 | INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC | STEP THERAPY |
| J1560 | INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, OVER 10 CC | STEP THERAPY |
| Q0138 | INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1MG (NON-ESRD USE) | STEP THERAPY |
| Q0139 | INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1MG (FOR ESRD ON DIALYSIS) | STEP THERAPY |
| Q5126 | INJECTION, BEVACIZUMAB-MALY, BIOSIMILAR, (ALYMSYS), 10 MG | STEP THERAPY |
| Q5127 | INJECTION, PEGFILGRASTIM-FPGK (STIMUFEND), BIOSIMILAR, 0.5 MG | STEP THERAPY |
| Q5128 | INJECTION, RANIBIZUMAB-EQRN (CIMERLI), BIOSIMIAR, 0.1 MG | STEP THERAPY |
| Q5129 | INJECTION, BEVACIZUMAB-ADCD (VEGZELMA), BIOSIMILAR, 10 MG | STEP THERAPY |
| Q5130 | INJECTION, PEGFILGRASTIM-PBBK (FYLNETRA), BIOSIMILAR, 0.5 MG | STEP THERAPY |