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WellFirst Health Medical Management

Authorization and coverage

Prior Authorization Services

Medical prior authorization service list

Injectables

Medical injectables list

Medical benefit prior authorization form

Medical oncology drugs (effective 1/1/2023)

Medical non-oncology drugs (effective 10/1/2023)
 
Exception to coverage forms
For new FDA approved drugs on the market for less than a year that have not been reviewed or granted approval through the Pharmacy & Therapeutics Committee.
Pharmacy drug-IL
Pharmacy drug-MO
Medical injectable drug-IL
Medical injectable drug-MO
Medicare injectable drug step B therapy
Medicare pharmacy drug step B therapy

Non-covered

Non-covered services

Non-covered durable medical equipment & supplies

Information & forms

WellFirst Health policies

  • Medical policies
  • Drug policies
  • Medical oncology drugs (effective 1/1/2023)
  • Medical non-oncology drugs (effective 10/1/2023)
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Prior authorization

  • Radiology/NIA
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Prior authorization forms

Illinois
  • Behavioral health
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  • Outpatient
  • Skilled nursing facility/swing bed

Missouri
  • Behavioral health
  • Dental
  • Durable medical equipment
  • Home health/hospice
  • Outpatient
  • Skilled nursing facility/swing bed
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