Medicare Health Plans >> Drug Management Programs

Medicare Health Plans

Drug Management Programs

For certain prescription drugs, Welborn Health Plans have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and/or pharmacists developed these requirements and limits for our Plan to help us to provide quality coverage to our members.

The requirements for coverage or limits on certain drugs are listed as follows:   

• Prior Authorization : We require you to get prior authorization (prior approval) for certain drugs. This means that authorized prescriberswill need to get approval from us before you fill your prescription. If they don’t get approval, we may not cover the drug.
• Quantity Limits : For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, we will provide up to 6 units per prescription for Relpax.
• Step Therapy : In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.
• Generic Substitution : When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug.

You can find out if the drug you take is subject to these additional requirements or limits by looking in the formulary on our formulary website or by calling Member Services. If your drug is subject to one of these additional restrictions or limits and your physician determines that you aren’t able to meet the additional restriction or limit for medical necessity, you or your physician can request an exception (which is a type of coverage determination).

If you have any questions, please call or write to:

Welborn Health Plans Customer Services
101 S.E. 3rd St
Evansville, IN 47708
(812) 426-6600
Toll Free: 1-800-521-0265
TTY users, call Indiana Relay: 1-800-743-3333
FAX: (716) 541-6386

Pharmacy 24-hour Customer Care:
Phone: 1-888-816-7981
TTY: 1-866-236-1069

 

 

Beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for up to one hundred (100) percent of drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.

Updated 10/2010

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