Providers

Professional Resources

Report an Adverse Drug Event

Learn more about specific medications

Learn more about WithMe Health Benefit Management Procedures

Utilization management (UM)

If you would like a copy of our UM criteria or have questions about our coverage decision process, please contact our guide team at 1-866-840-1877.

Member Cost Share

If you have questions regarding medication copays and formulary tiers, please contact our guide team at 1-866-840-1877.

Prior Authorization/Exception Requests and Appeals may be submitted via the following methods:

Mail: WithMe Health
ATTN: Member Services
204 E 2nd Ave #337
San Mateo, CA 94401
Fax: 1-866-678-8301
Phone: 1-866-840-1877

Prescriber Specific Resources

Thank you for visiting our Prescriber Resource page. This area is designed to assist you with quickly finding information regarding the WithMe Health Formulary, Coverage Decision & Appeals Process as well as our Medication Guide Program.

All WithMe Health Clinical Programs, including those related to drug utilization management, are developed with oversight from our P&T Committee comprised of practicing pharmacists and physicians that have a wide variety of specialties. This information is available upon request. If you have questions, please contact us at 1-866-840-1877.

WithMe Health encourages feedback on the WithMe Health Drug Therapy Management (DTM) program. Please complete a brief satisfaction survey that will to aid in program improvements.

Formulary Information

WithMe Health’s formulary (list of covered drugs) is developed & maintained by a Pharmacy & Therapeutics (P&T) Committee. The P&T Committee is made of practicing pharmacists and physicians that have a wide variety of specialties. The formulary is reviewed and updated as new drugs enter the marketplace or when new drug information becomes available. The Committee bases their decision to place a drug on the formulary on the following items:

• safe use of the medication
• clinical efficacy of the medication
• therapeutic need

Cost is considered only after these factors are taken into account. Following the formulary is important for improving quality of care and managing health care costs. Generic drugs are covered on the formulary and are a way to help control your patients out of pocket costs. Some plans require your patients to use generic drugs when available.

PLEASE NOTE: The list(s) below may be subject to change. Not all drugs listed are covered by all prescription-drug benefit programs. For specific questions about your patients' coverage, including their cost share, less expensive alternatives, as well as if they have a mandatory mail order benefit, please call the WithMe Health Guide Team at 1-866-840-1877.

• 2022 WithMe Health Plus Formulary
  
• Affordable Care Act Preventive Drug List
  
• Prior Authorization Drug List
• Quantity Limit List

Prior Authorization/Formulary Exception Request Forms

Below you will find various prior authorization/exception forms to complete for your patient. Please note, we do not require or solicit extraneous information that is not consistent with the criteria necessary to complete a review criteria. You are not required to submit the member’s entire medical records but only data relevant to the clinical parameters of the prescription.

Please fax completed Prior Authorization Forms to 1-866-678-8301 or call 1-866-840-1877 to complete an authorization over the phone.

• General Prior Authorization Request Form
• Cystic Fibrosis PA Form
• Descovy/Truvada PA Form
• Erectile Dysfunction PA Form
• Hemophilia PA Form
• Hepatitis C PA Form
• Long Acting Opioids PA Form
• Praulent_Repatha Form PA Form
  
• RA/Crohn's/Psoriasis PA Form
  
• Weight Loss PA Form
• Acthar Non-Formulary Exception
• Non-Formulary Exception
• Quantity Limit Exception
• Step Therapy Exception

State Specific Prior Authorization Forms

• State of California Prior Authorization Form
• State of Colorado Prior Authorization Form
• State of Illinois Prior Authorization Form
• State of Iowa Prior Authorization Form
• State of Louisiana Prior Authorization Form
• State of Massachusetts Prior Authorization Form
  
• State of Oregon Prior Authorization Form
• State of Texas Prior Authorization Form

Pharmacy Specific Resources

Thank you for visiting our Pharmacy Resource page. This area is designed to assist you with quickly finding information regarding the WithMe Health pharmacy network and how to submit a claim.

Our guide team is available to assist with answering claim submission questions or network issues 24 hours a day, 7 days a week by calling 1-866-840-1877.

• Payor Sheet