Utilization Management (Prior Authorization Requirements and Step Therapy Requirements)

Allwell has a team of doctors and pharmacists that create tools to help us provide quality coverage to our members. The tools include‚ but are not limited to: prior authorization and step therapy criteria‚ clinical edits and quantity limits. Some examples include:

  • Age Limits: Some drugs require a prior authorization if your age does not meet the manufacturer, FDA, or clinical recommendations.
  • Quantity Limits: For certain drugs, Allwell limits the amount of the drug we will cover per prescription or for a defined period of time.
  • Prior Authorization: We require you to get prior authorization for certain drugs. (You may need prior authorization for drugs that are on the formulary or drugs that are not on the formulary and were approved for coverage through our exceptions process.) This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, Allwell may not cover the drug.
  • Step Therapy: For certain drugs, we require you to try a less expensive alternative before “stepping up” to drugs that cost more.
  • Maintenance (Mail Order) Drugs: Certain drugs are available through our mail order pharmacy.  Look for “MO” in our formulary to see if your drugs are eligible for our mail-order service.

You can ask Allwell to make an exception to our coverage rules. For specific types of exceptions that you can ask us to make, please refer to the  Formulary. When you are requesting a utilization restriction exception you should submit a statement from your doctor supporting your request along with a completed Request for Medicare Prescription Drug Coverage Determination form. Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing doctor’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing doctor’s supporting statement.

Please see the Coverage Determinations, Exceptions and Redeterminations page for more information.

If you have questions about our formulary or want to get the most recent list of drugs, call us.  We are here to help!

Please select the document for your plan and county:

For HMO Members:

Plan Name County Maintenance Drug Document
Allwell Medicare (HMO)

Duval, Lake, Pinellas, Polk, and Volusia counties

  • English- Maintenance Drug Document
  • Espanol- Maintenance Drug Document   
Allwell Medicare Premier (HMO)

Duval, Hernando, Pasco, Pinellas, Polk, and Volusia counties

  • English- Maintenance Drug Document
  • Espanol- Maintenance Drug Document   
Allwell Medicare (HMO)

Manatee, Marion, Palm Beach, and Seminole counties

  • English- Maintenance Drug Document
  • Espanol- Maintenance Drug Document   
Allwell Medicare (HMO)

Miami-Dade county

  • English- Maintenance Drug Document
  • Espanol- Maintenance Drug Document   
Allwell Medicare (HMO) Hillsborough county
  • English- Maintenance Drug Document
  • Espanol- Maintenance Drug Document   
Allwell Medicare (HMO) Osceola county
  • English- Maintenance Drug Document
  • Espanol- Maintenance Drug Document   
Allwell Medicare (HMO) Orange county
  • English- Maintenance Drug Document
  • Espanol- Maintenance Drug Document  
Allwell Medicare (HMO) Broward county
  • English- Maintenance Drug Document
  • Espanol- Maintenance Drug Document  

For HMO SNP Members:  

Plan Name County  Maintenance Drug Document
Allwell Dual Medicare (HMO SNP)

Baker, Duval, Hardee, Hernando, Manatee, Marion, Martin, Polk, and Volusia counties

  • English- Maintenance Drug Document
  • Espanol- Maintenance Drug Document   
Allwell Dual Medicare (HMO SNP)

Hillsborough, Lake, Orange, Osceola, Pasco, Pinellas, Seminole, St. Lucie counties

  • English- Maintenance Drug Document
  • Espanol- Maintenance Drug Document   
Allwell Dual Medicare (HMO SNP)

Broward and Palm Beach counties

  • English- Maintenance Drug Document
  • Espanol- Maintenance Drug Document   
Allwell Dual Medicare (HMO SNP)

Miami - Dade county

  • English- Maintenance Drug Document
  • Espanol- Maintenance Drug Document   

Please select the document for your plan and county:

For HMO Members:

Plan Name County Quantity Limit Listing Document
Allwell Medicare (HMO)

Duval, Lake, Pinellas, Polk, and Volusia counties

  • English- Quantity Limit Listing Document
  • Espanol- Quantity Limit Listing Document 
Allwell Medicare Premier (HMO)

Duval, Hernando, Pasco, Pinellas, Polk, and Volusia counties

  • English- Quantity Limit Listing Document
  • Espanol- Quantity Limit Listing Document   
Allwell Medicare (HMO)

Manatee, Marion, Palm Beach, and Seminole counties

  • English- Quantity Limit Listing Document
  • Espanol- Quantity Limit Listing Document   
Allwell Medicare (HMO)

Miami-Dade county

  • English- Quantity Limit Listing Document
  • Espanol- Quantity Limit Listing Document    
Allwell Medicare (HMO) Hillsborough county
  • English- Quantity Limit Listing Document
  • Espanol- Quantity Limit Listing Document 
Allwell Medicare (HMO) Osceola county
  • English- Quantity Limit Listing Document
  • Espanol- Quantity Limit Listing Document 
Allwell Medicare (HMO)

Orange county   

 
Allwell Medicare (HMO) Broward county  

For HMO SNP Members:  

Plan Name County  Quantity Limit Listing Document
Allwell Dual Medicare (HMO SNP)

Baker, Duval, Hardee, Hernando, Manatee, Marion, Martin, Polk, and Volusia counties

  • English- Quantity Limit Listing Document
  • Espanol- Quantity Limit Listing Document    
Allwell Dual Medicare (HMO SNP)

Hillsborough, Lake, Orange, Osceola, Pasco, Pinellas, Seminole, St. Lucie counties

  • English- Quantity Limit Listing Document
  • Espanol- Quantity Limit Listing Document 
Allwell Dual Medicare (HMO SNP)

Broward and Palm Beach counties

  • English- Quantity Limit Listing Document
  • Espanol- Quantity Limit Listing Document   
Allwell Dual Medicare (HMO SNP)

Miami - Dade county

  • English- Quantity Limit Listing Document
  • Espanol- Quantity Limit Listing Document    

 

HMO Reconsideration Form 

HMO SNP Redetermination Form 

HMO SNP Redetermination Form 

HMO Reconsideration Form 
  • English- Prior Authorization Criteria
  • Espanol- Prior Authorization Crtieria
  • English- Step Therapy Criteria
  • Espanol- Step Therapy Crtieria


Last Updated: 06/30/2017
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