Pharmacy programs

WellSense uses a number of pharmacy programs to promote the safe and appropriate use of certain drugs. These drugs have clinical guidelines that must be met before the Plan will cover them. Check to see if a prescription drug is covered by our plans.

If a healthcare provider feels that it is medically necessary for you to take a medication that is not covered by your plan, the provider may submit a request to WellSense using the appropriate prior authorization request form. We will review the request and if it meets certain criteria, we will cover the drug. If the request is denied, you or an authorized representative can appeal the decision.

Read more about our pharmacy programs below.

The Prior Authorization program requires that WellSense members meet specific clinical conditions before a drug can be covered. If a drug falls into this group and may be medically necessary for you, your provider can submit a request to us to cover your prescription, or you can start a request yourself by calling Express Scripts at 1-877-417-0528.

The Step Therapy program requires that members first try one drug to treat a medical condition before we will cover another drug for that condition. If the first level treatment is not tried, prior authorization is required.

The Mandatory Generic Substitution Program requires a member to try an AB rated generic drug before its brand counterpart would be covered. The Food and Drug Administration (FDA) has determined certain generic drugs are therapeutically equivalent (AB rated) to their brand counterparts. This means that the AB rated generic drug is as effective as its brand name drug. Massachusetts law also requires the dispensing of the AB rated generic drug, unless the provider indicates the brand is medically necessary.

WellSense reviews new drugs for safety and efficacy before we add them to our formulary. New drugs require prior authorization until they are reviewed by our Pharmacy and Therapeutics Committee, which is composed of doctors, pharmacists and other healthcare professionals.

The Quantity Limitation Program ensures the safe and appropriate use of some medications by covering a specific amount that can be dispensed at one time. Quantities greater than the specified amount require prior authorization for coverage.

The Specialty Pharmacy Program requires that some drugs be supplied by a specialty pharmacy. These drugs include injectable and intravenous drugs that are often used to treat chronic conditions, like Hepatitis C or multiple sclerosis, which require additional expertise and support. Specialty pharmacies have knowledge in these areas and can provide additional support to members and providers. WellSense contracts with the following specialty pharmacies to provide these drugs:

  • Cornerstone Health Solutions: 844-319-7588
  • Boston Medical Center Outpatient Pharmacy YACC: 617-414-4883

Use our drug search tool to see which drugs must come from a specific specialty pharmacy.

The Prescription Drug Monitoring Program (PDMP) was created to find members who may not be using certain medications properly. The medications included in this program are called "schedule II-IV controlled substances". These are drugs, for example OxyContin and benzodiazepine, that are tightly controlled by the government because they tend to encourage overuse in some people. Other medications included in the program, such as gabapentin and tramadol, though they are not as tightly controlled, also tend to be overused. Members are automatically enrolled into the program if their medical history matches a pre-defined set of rules designed to identify members who should be enrolled into the program. Health care providers can also ask for members to be enrolled into the program.

Once enrolled, the member’s history, including emergency room visits, doctor’s office visits, and medication use is used to decide what the right action is. These actions may include notifying health care providers of the situation, and only allowing a single pharmacy and/or physician (or group of physicians) to handle prescriptions for the member. In some cases, a Fraud and Abuse referral may be needed. The main reason for taking these actions is to help members improve the quality of their life by giving their health care providers a better picture of the member’s condition, and a better chance to prevent possible medication misuse. We also encourage members to try to understand their own condition and to share information about their medication use with their health care providers. To learn more about the program, please call the WellSense Member Services phone number on the back of your card.

WellSense members may choose to have maintenance medications sent to their homes from Cornerstone Health Solutions instead of filling prescriptions at a local retail pharmacy. Maintenance drugs are medications that are filled regularly for conditions such as diabetes, asthma, high cholesterol and high blood pressure. Members enrolled in this program receive up to a 90-day supply of their medication with each refill.

Learn how to enroll in our mail order pharmacy program.