Q&A: Pharmacy benefit guideline

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
 
  • Prior authorization (PA): WellFirst Health — provided by SSM Health Plan — requires you (or your physician) to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don’t get approval, WellFirst Health may not cover the drug.
  • Prior authorization restriction for part B vs part D determination (PA BvD): This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from WellFirst Health to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, Dean Advantage may not cover this drug.
  • Prior authorization restriction for new starts only (PA NSO): If you are a new member, you (or your physician) are required to get prior authorization from WellFirst Health before you fill your prescription for this drug. Without prior approval, WellFirst Health may not cover this drug.
  • Quantity limits (QL): For certain drugs, WellFirst Health limits the amount of the drug that we will cover. For example, WellFirst Health provides nine tabs per prescription for sumatriptan tab.
  • Step therapy (ST): In some cases, WellFirst Health requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if drug A and drug B both treat your medical condition, we may not cover drug B unless you try drug A first. If drug A does not work for you, WellFirst Health will then cover drug B.
  • Non-mail-order drug (NM): You may be able to receive greater than a one-month supply of most of the drugs on your Formulary via mail order at a reduced cost share. Drugs not available via your mail-order benefit are noted with “NM” in the notes column of your Formulary.
  • Limited distribution (LD): The symbol (LD) next to a drug name indicates that the drug has been noted as being restricted to certain pharmacies by the Food and Drug Administration. These drugs can only be obtained at specialty designated pharmacies able to appropriately handle the drugs.
Generally, if you are taking a drug on our current year formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released.

Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug.

If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.
Generally, WellFirst Health will only approve your request for an exception if the alternative drugs included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You can ask WellFirst Health to make an exception to our coverage rules. See the Part D Drug Coverage Determination, Exceptions, Appeals and Grievance page for more information. There are several types of exceptions that you can ask us to make:
  • You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
  • You can ask us to cover a formulary drug at a lower cost-sharing level (if this drug is not on the specialty tier). If approved this would lower the amount you must pay for your drug.
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Contact us to ask for an initial coverage decision for a formulary or utilization restriction exception.

When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request.

Generally, we must make our decision within 72 hours of getting your prescriber’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 a supporting statement from your doctor or other prescriber.
Review the Pharmacy Transition Process page to learn more about exceptions when you are a new member or other special situation.

As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription.

You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
If your drug is not included in the formulary, you should first contact our Customer Care Center and ask if your drug is covered. If you learn that WellFirst Health does not cover your drug, you have two options:

You can ask our Customer Care Center for a list of similar drugs that are covered by WellFirst Health. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that we cover.

You can ask WellFirst Health to make an exception and cover your drug. See below for information about how to request an exception.

Questions? Contact us.

Senior man using phone and laptop in his living room.Members
Talk with our Customer Care Center at 1-877-301-3326 (TTY:711).
 
Not a member?
Talk with a WellFirst Health Medicare sales rep at 1-833-551-0565. You can also call to ask for information in alternate formats and languages. 

Mailing address

WellFirst Health Medicare Advantage
PO Box 56099
Madison, WI 53705-9399
 
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Updated 10/1/20