Utilization management for prescription drugs

Additional requirements

Some covered medications have additional requirements or limits on coverage. Limits on coverage include prior authorization, step therapy and quantity limits. If a medication you are taking has prior authorization, step therapy requirements or quantity limitations, please download and complete the specific drug’s prior authorization form, and ask your doctor or other prescriber to fax it to us at 1-855-668-8552.

Prior authorization

Some covered drugs require approval in advance to get coverage. Prior approval is used for drugs that are and are not on our formulary. Some medications are covered only if your doctor or other network provider gets a prior authorization from us. Covered medications that need prior authorization are marked in the formulary.

Prior authorization criteria

Prior authorization forms

Note:

  • Requests for coverage may be denied or dismissed unless all required information is received.
  • Your provider’s office will receive a response via fax.
  • For urgent requests, call 1-866-270-3877 (TTY: 711).

Step therapy

Prior to receiving coverage, a trial of another medication(s) is necessary. A Prior Authorization form may be required. Some medications do not require a PA form/exception request if the prior medication(s) have been filled within the pharmacy claims system.

2021 Step therapy criteria

2021 Step B therapy medical list Exception to coverage form

Quantity limits

WellFirst Health — provided by SSM Health Plan — Medicare Advantage requires that some prescription drugs have quantity limits to ensure quality, safety and proper use. We may limit the amount of the medication we cover per prescription or for a defined period of time.

The quantity listed is the quantity-per-month limitation. For WellFirst Health, the drug benefit typically allows coverage for a 30-day supply unless the medication is available at a 90-day supply through mail order or at retail location per prescription claim.

Notice of formulary updates

Generally, if you are taking a medication listed on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of that medication during the coverage year except when a new, less expensive generic medication becomes available or when information is released that calls into question the safety or effectiveness of a medication. Other types of formulary changes, such as removing a medication from our formulary, will not affect members who are currently taking that medication. It will remain available at the same cost-sharing for the remainder of the coverage year, except for in cases in which you can save additional money or we can ensure your safety.

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
 
View our Medicare disclaimers.

H8019_wellfirstbenefits.com
Updated 10/16/20