WellFirst Health Medical Management

Medical prior authorization service list

Medical injectables list

Medical benefit prior authorization form

Medical oncology drugs (effective 1/1/2023)

Medical non-oncology drugs (effective 10/1/2023)

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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 services

Non-covered durable medical equipment & supplies