The Medicare Advantage plan prior authorization form from WellFirst Health — Provided by SSM Health Plan — can be used to to request authorization of services that require prior authorization, including medical drug injectables. See our Medical Service List for services that require prior authorization and to submit prior authorization requests.
Services will be reviewed according to the Medicare Coverage Guidelines, established by the Centers for Medicare & Medicaid Services (CMS). According to the guidelines, all medical care, services, supplies and equipment must be medically necessary.
In scenarios where CMS does not provide guidance on the particular medical care, service, supplies and equipment, we will use MCG (formerly Milliman Care Guidelines) criteria or a WellFirst Health — Provided by SSM Health Plan — medical policy. See the our Medical Services Prior Authorization List to access the medical policies relevant to the services you are requesting.
Additional Information about medical management can be found on our Medical Management page. Key resources include: