Some drugs have special requirements that must be met before WellFirst Health — Provided by SSM Health Plan — will cover them. Those requirements are:
If your physician believes you require a certain medication that is not on your formulary, normally requires step therapy or exceeds a quantity limit, he or she may request an exception through the preauthorization process.
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.
2022 Prior authorization criteria – updated 6/2/22
Before some medications are approved, a different medication must be tried first. This first medication may or may not require a prior authorization.
2022 Step therapy criteria – updated 6/2/22
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 — Provided by SSM Health Plan — 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.
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.
See the rest of our list of drugs with special requirements.