Pharmacy Information

Medicaid and CHIP

Explore pharmacy resources exclusive to our Medicaid and CHIP care providers.

Wellpoint pharmacy contact information

Retail pharmacy help desk

Call: 888-483-0801

Medicaid and CHIP prior authorization for physician-administered drugs

Call: 877-375-6185

Fax: 844-487-9290

Medicaid and CHIP pharmacy benefits manager (PBM)

Wellpoint manages provider-administered drugs for enrolled members. Retail pharmacy benefits are covered under the fee-for-service program.

National Drugs Codes (NDCs)

Care providers must include National Drug Codes (NDCs), unit of measurement, and quantity of drug on all Wellpoint claims, including physician-administered drugs. This applies to drugs dispensed in both professional and institutional outpatient settings.

West Virginia’s Bureau for Medical Services (BMS) requires Wellpoint report NDC information every month. BMS submits this data to pharmaceutical manufacturers to obtain rebates under the Medicaid Drug Rebate Program. Following these instructions is important for West Virginia to receive timely Medicaid drug rebates from drug manufacturers.

Preferred drug list (PDL) inquiries

The PDL is part of the pharmacy service provided by the West Virginia Bureau for Medical Services (BMS).

West Virginia Preferred Drug List (PDL)

West Virginia Bureau for Medical Services (BMS)

Physician-administered drug requirements

Wellpoint will deny professional and outpatient institutional claims containing physician-administered drugs if any of the following elements are missing or invalid:

NDC*
Unit of measurement
Quantity of drug

*The NDC is an 11-digit code on the package or container from which medication is administered.

Outpatient infusion pharmaceuticals

Billing requirements for outpatient infusion pharmaceuticals apply to drugs such as chemotherapy, hydration and antibiotics used during each outpatient infusion therapy visit. An important exception is for blood and blood products, which are billed under the 'Other Services' category. Specific codes and service dates are required; guidance for relevant billing and HCPCS codes can be found in the provider manual.

Clinical criteria

The West Virginia State Specific clinical criteria for injectable, infused or implanted physician administered drugs and therapies covered under the medical benefit are available for West Virginia Medicaid market. All clinical criteria aligns with the West Virginia Bureau of Medical Services Preferred Drug List.

For prior authorization requirements specific to pharmaceuticals including specialty medications, please visit the prior authorization requirements page.

Medical Injectables Prior Authorization Form

Medicare

Explore pharmacy resources exclusive to our Medicare care providers.

Medicare prior authorization requests

Prior authorization requests may be telephoned, submitted online, or faxed to Wellpoint. For more information, refer to your Medicare Provider Manual.

Medicare pharmacy benefits manager (PBM)

Wellpoint administers Medicare pharmacy benefits for enrolled members, and CarelonRx is the pharmacy benefits manager. Most medications are covered without prior authorization, but a few require prior approval from our pharmacy department.

CarelonRx

Call the Medicare pharmacy department: 833-377-4266 