Provider : Coverage Determination

 

WellCare Advocate Complete FIDA will no longer be part of the FIDA program effective January 1, 2017.
 

Providers should continue to bill for covered services rendered for eligible dates of service. The secure provider portal will continue to be available for WellCare Advocate Complete FIDA providers.
 

The coverage determination process for prior authorization ensures that medication regimens that are high risk, have a high potential for misuse, or narrow therapeutic indices are used appropriately and according to FDA-approved indications.

 

You may request a coverage decision and/or exception the following ways:

 

Online:

 

Call: Please refer to the Quick Reference Guide for the appropriate phone number.


The coverage determination process is required for:

 

  • Drugs not listed on the formulary;
  • Drugs listed on the formulary with a prior authorization;
  • Duplication of therapy;
  • Prescriptions that exceed the FDA daily or monthly quantity limits or prescriptions exceeding the permitted noted on the formulary;
  • Most self-injectable and infusion drugs (including chemotherapy) administered in a physician’s office; and
  • Drugs that have a step edit (ST) and the first line therapy is inappropriate.  
     
Last modified: 01/12/2017
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