Pharmacy medical management policies

Our medical management includes:

• Prior Authorizations forms for medical injectables drugs. See our Pharmacy Medical Injectable Prior Authorization List and our Medicare Advantage Prior Authorization form or our drug specific drug criteria located on the Navitus site.
• Preferred and non-preferred drug list for Medical Step B injectable drugs. See our 2023 Medical step B therapy list (updated 8/1/2023) and exception to coverage form.

Our medical policies

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 Prior Authorization Medical Service List to access the medical policies relevant to the services you are requesting. See our Medicare Advantage Prior Authorization form. 

Additional information

Additional Information about medical management can be found on our Medical Management page. Key resources include:

• Radiology policies (NIA/Magellan Health)
• Behavioral health 
• Physical medicine policies (NIA/Magellan Health)
• Musculoskeletal program (NIA/Magellan Health) 

Questions? Contact us.

Members

Talk with our Customer Care Center at 608-828-1978 (TTY: 711).
8 am to 8 pm weekdays (year-round) and weekends (Oct. 1 – March 31)