Before administering a service or prescribing a drug, it is important to know whether a member has coverage under their pharmacy or medical benefits. Wellmark encourages providers to verify membership and review the medical authorization table, drug authorization list, and the member’s drug list first. Providers are also encouraged to contact Wellmark customer service to verify benefits as some plans have medication/service exclusions not shown in the drug list.
For most benefits, there is an evaluation period before adding new, FDA-approved brand-name prescription drugs to the formulary or to medical coverage after the prescription drug receives an FDA approval. During this evaluation period, the drug will be considered non-covered while the Wellmark Pharmacy & Therapeutics (P&T) Committee reviews the clinical evidence available, including but not limited to, the drug’s safety, efficacy, and place in therapy.
If, following the P&T evaluation, it is determined that a drug should be covered and managed through medical policy or prior authorization, the policy and the drug will be added to the medical authorization table or drug authorization list. The formulary will also be updated.
The medical authorization table provides the medical policies and criteria used by Wellmark and is the first stop in learning whether an authorization is required.
Be sure to obtain approval in advance to help prevent delays and unexpected costs.
Verify authorizationView Authorization Table Search Out-of-Area Authorizations
Submit or check authorization or view statusMedical Secure Site Molecular Testing
Some drugs, and certain amounts of some drugs, require an approval before they are eligible for coverage. The drugs listed below require prior authorization.
Click the drug name or policy name to view the clinical criteria.
Verify authorizationView Drug Authorization List
Submit authorization or view statusSubmit Drug Authorizations Secure Site Check Authorization Status Drug Authorization Secure Site
Manage medical and drug authorizations
Some medical services, procedures, durable medical equipment (DME) and drugs require approval before they can be covered by your patients' benefits.
Upon receiving approval, you will be given an authorization number. Please reference this number on all claims related to the specific procedure or service requiring prior approval. Also, remember that services determined as not medically necessary, investigational, or experimental are the liability of the provider.
User guides & resources
JivaTMMedical Authorization user guide (Jiva) Secure Site
Jiva quick guide for submitting inpatient (IP) requests Secure Site
Jiva quick guide for submitting outpatient (OP) requests Secure Site
Jiva quick guide for submitting out of network (OON) requests Secure Site
Jiva quick guide for submitting extending stay or service requests Secure Site
InterQual Quick Reference Guide PDF File
InterQual® clinical review training video Secure Site
InterQual inpatient review training video (NEW)
Novologix®Drug Authorization User Guide (Novologix) PDF File
Novologix training video
Imaging Services Pre-Authorization Code Groupings Secure Site
Types of Authorizations
InterQual® Criteria and SmartSheetsTM
Prior Approval for Federal Employee Program (FEP) Members
Radiology pre-authorization requests Q&A Secure Site
Updated Medical Preferred Drug Strategies PDF File
Utilization management-related webinars Secure Site
View important details about authorizations
Inpatient Review FAQ PDF File