WellFirst Health Medical Management

Medical prior authorization service list

Medical injectables list

Medical benefit prior authorization form

Medical oncology drugs (effective 1/1/2023)

---

 

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 services
Non-covered durable medical equipment & supplies