Utilization management

Medical

• Medical prior authorization list – currently suspended until further notice
• Inpatient and post acute care services criteria
  • Wellmark Advantage Health Plan uses the nationally recognized medical necessity of InterQual for inpatient and post acute care prior authorization requests.
  • Wellmark Advantage^SM prior authorization form - for inpatient and post-acute medical necessity review. IMPORTANT: this form and fax number are for Wellmark Advantage members only. All other submissions will be destroyed.
• Skilled Nursing Facility and Inpatient Rehabilitation Assessment Form
• Long-Term Acute Care Hospital Assessment Form

Part B Drug

• Part B Drug Authorization List Changes – July 2026
• Part B medical drug prior authorization & step therapy list
• Part B Medical Drug Policy Criteria
• Part B References and Summary of Evidence
• Part B medical drug prior authorization form

Continuous glucose monitors and diabetic testing supplies

• Continuous glucose monitors policy
• Prior authorization form for continuous glucose monitors
• Diabetic testing supplies policy
• Prior authorization form for diabetic testing supplies

Authorization tool

Submit medical and Part B authorizations electronically through Symphony for Wellmark Advantage members.

• Symphony user guide
  • Symphony 6.0 Inpatient Quick Reference Guide
  • Symphony 6.0 Outpatient Quick Reference Guide
  • Symphony 6.0 Part B Drug Authorization Quick Reference Guide
• Medical prior authorization list – currently suspended until further notice
• Frequently Asked Questions – Utilization Management

Clinical decision support resources

Local and National Coverage Determinations

Medical Policies follow Medicare Advantage Policy Guidelines to comply with the Centers for Medicare & Medicaid Services (CMS) Policy, National Coverage Determinations (NCDs), and/or Local Coverage Determinations (LCDs), as applicable. See the Medicare Coverage Database for the most current NCD, LCD, Local Coverage Articles (LCAs) and CMS Online Manual System/Transmittals.