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Pharmacy Resources
We are committed to providing appropriate, high-quality, and cost-effective drug therapy to all WellCare of North Carolina members. These resources below provide helpful information on how to get the most out of your prescription drug benefits.
Formulary
Copayment – Tier Level
What is a pharmacy drug tier? How does it work?
All covered drugs are assigned a tier. Depending on the tier the drug is in, you may have different cost-share associated with that drug. Please consult the table below for detailed description of drug tiers. Your physician can prescribe you a product in any tier, however there may be more cost-effective options on lower tiers. You can speak with your physician about what drug might be appropriate for you. Here’s a look at the different tiers:
| Tier Level | Description |
|---|---|
| Tier 0 | No copayment for those drugs that are used for prevention and are mandated by the Affordable Care Act. Select oral contraceptives, vitamin D, folic acid for women of child bearing age, over-the-counter (OTC) aspirin, and smoking cessation products may be covered under this tier. Certain age limits may apply. |
| Tier 1A | Lowest copayment for select drugs that offer the greatest value compared to other drugs used to treat similar conditions. Select over-the-counter (OTC) drugs may be covered under this tier. |
| Tier 1B | Low copayment for those drugs that offer great value compared to other drugs used to treat similar conditions. Select over-the-counter (OTC) drugs may be covered under this tier. |
| Tier 2 | Medium copayment covers brand name drugs that are generally more affordable, or may be preferred compared to other drugs to treat the same conditions. |
| Tier 3 | High copayment covers higher cost brand name and non-preferred generic drugs. This tier may also cover nonspecialty drugs that are not on the Prescription Drug List but approval has been granted for coverage. |
| Tier 4 | Highest copayment is for “specialty” drugs used to treat complex, chronic conditions that may require special handling, storage or clinical management. Prescription drugs covered under the specialty tier may require fulfillment at a pharmacy that participates in Ambetter's "specialty" or "hemophilia" networks. |
Prescription Delivery
Save Money and Get Your Prescriptions Delivered to Your Door!
As an WellCare of North Carolina member, you can maximize your pharmacy benefits by filling your prescriptions by mail. Eligible members may save when ordering a 90-day supply*. Delivery is free and can be to your home, workplace or any address you choose.
Prescription delivery may be right for you if you take medications regularly for conditions like high blood pressure, arthritis or diabetes.
Two easy ways to get started:
- Call your provider and ask them to send a new 90-day prescription to Express Scripts® Pharmacy.
- Or request prescription delivery in your online member account.
*Members may save when they fill eligible medications, 90 days at a time, through Express Scripts® Pharmacy.
AcariaHealth
Need a specialty pharmacy for your complex or chronic conditions? Prescription home delivery is available to you.
Get your specialty medications mailed directly to your door, free of charge. AcariaHealth offers specialty prescription delivery services for those living with complex conditions or chronic illnesses, such as rheumatoid arthritis, multiple sclerosis, hepatitis C or cancer. AcariaHealth’s licensed pharmacists are also available to you 24/7 to discuss prescribed therapy and answer any questions regarding medications and supplies.
AcariaHealth will work with your current specialty pharmacy provider to seamlessly transition your medications safely and efficiently. To get started, contact us at 1-800-511-5144.
Hemophilia Network
Please refer to the link below for a comprehensive listing of WellCare of North Carolina's in-network hemophilia pharmacies.
Pharmacy FAQ
This is the sharing of costs under your insurance plan that you pay out of your pocket. This includes items such as copays, deductibles, and coinsurance. Cost sharing does not include premiums, balance billing amounts to non-network providers, or the cost for non-covered services.
A copay is the set amount of money you pay at the time of certain medical services, such as doctor visits or picking up prescriptions. The copay amount for your prescriptions may vary depending on the tier of your prescription coverage.
A formulary is a list of generic and brand-name drugs covered by your health plan. They are listed in tiers based on the drug type. Drugs in lower tiers will cost less than drugs in higher tiers.
A deductible is a set dollar amount you are responsible for before your health plan will start paying for health services. Drugs may or may not be subject to the deductible, based on the tier.
If the tier is not subject to the deductible, you will pay only the cost-share for that drug tier. If the tier is subject to the deductible, you will first have to pay the deductible before you start paying the cost-share of that tier.
A member can have prescriptions filled at a WellCare network pharmacy. If the member decides to have a prescription filled at a network pharmacy, they can locate a pharmacy near them by contacting WellCare Member Services at 1-833-925-2861 (TTY 711).
A member can also use the Find a Provider Tool on the website to locate in-network pharmacies. At the pharmacy, the member will need to provide the pharmacist with the prescription and their WellCare ID card.
Generic drugs have the same active ingredient and work the same as brand-name drugs.
When generic drugs are available, the brand-name drug will not be covered without WellCare authorization. If the member or their physician feels a brand-name drug is medically necessary, the physician requests the drug using the prior authorization process.
We will cover the brand-name drug according to our clinical guidelines if there is a medical reason the member needs the brand-name drug. If WellCare does not grant authorization, we will notify the member and their physician and provide information regarding the appeal process.
Some drugs listed on the Formulary/Prescription Drug List (PDL) may need prior authorization. The information should be submitted by the physician or pharmacist to Centene Pharmacy Services on the Prior Authorization Request Form for Non-Specialty Drugs. The form should be faxed to Centene Pharmacy Services at 1-800-977-4170.
Authorization requests are reviewed by a licensed clinical pharmacist using the criteria set by the WellCare Pharmacy and Therapeutics (P&T) Committee. If the request is approved, CPS Pharmacy Drug Utilization team notifies the physician by fax. If the clinical information does not meet the coverage criteria for the requested medication, WellCare will notify the member and their physician of alternatives and provide information about the appeal process.
A provider can also submit a PA request through Cover My Meds.
For more about prior authorizations, see the “Prior Authorization” section in your Evidence of Coverage.
If your drug is not covered by our formulary, your provider can request a non-formulary exception request. Your provider can submit the non-formulary exception the same way as a regular prior authorization.
Some medications listed on the WellCare Formulary/Prescription Drug List (PDL) may require specific medications to be used before the member can receive the step therapy medication. If WellCare has a record that the required medication was tried first, the step therapy medications are automatically covered.
If WellCare does not have a record that the required medication was tried, the member’s physician may be required to provide additional information. If authorization is not granted, WellCare will notify the member and their physician and provide information regarding the appeal process.
WellCare of North Carolina may limit how much of a certain medication a member can get at one time. If the physician feels the member has a medical reason for getting a greater amount, a prior authorization may be requested. If WellCare does not grant prior authorization, we will notify the member and their physician and provide information about the appeal process.
Some drugs on the WellCare Formulary/Prescription Drug List (PDL) may have age limits. These are set for certain drugs based on FDA-approved labeling, safety concerns, and quality standards of care.