Pharmacy Programs

WellSense uses a number of pharmacy programs to promote the safe and appropriate use of certain drugs.

MassHealth has updated its list of covered drugs, effective 4/1/2023. Please use the link below to check if your drug is covered.

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 prior authorization to WellSense using the appropriate prior authorization forms. 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 prior authorization request for us to cover your prescription, or you can start a request yourself by

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 a drug falls into this group and may be medically necessary for you, your provider can submit a prior authorization request for us to cover your prescription, or you can start a request yourself by

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 equivalent. Massachusetts law also requires the dispensing of the AB rated generic drug, unless the provider indicates the brand is medically necessary.

If a drug falls into this group and may be medically necessary for you, your provider can submit a prior authorization request for us to cover your prescription, or you can start a request yourself by

 

New drugs are reviewed by our Pharmacy and Therapeutics Committee for safety and efficacy before they are added to the WellSense formulary.

If a drug falls into this group and may be medically necessary for you, your provider can submit a prior authorization request for us to cover your prescription, or you can start a request yourself by

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. 

If a drug falls into this group and may be medically necessary for you, your provider can submit a prior authorization request for us to cover your prescription, or you can start a request yourself by

 

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.

Visit our Specialty Pharmacy page for more details.

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, such as 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 predefined set of rules designed to identify members who should be enrolled into the program. Healthcare 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 the right action. 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 healthcare 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 healthcare providers. To learn more about the program, please call the WellSense Member Services phone number on the back of your card.

WellSense requires a 90-day supply be dispensed on certain drugs, and allows up to a 90-day supply on others.  Select drugs, like specialty drugs, are limited to a 30-day supply.  Visit the MassHealth Drug List for more information – check the Drug Notes to find the day-supply for your drug:

  • Mandatory 90-Day Supply (M90): After dispensing up to a 30-day supply initial fill, dispensing a 90-day supply is required.
  • Allowable 90-Day Supply (A90):  Dispensing in up to a 90-day supply is allowed.
  • Limited to 30-Day Supply (all others): Limited to dispensing a 30-day supply.
An easy way to obtain a 90-day supply of your medication is through a mail order pharmacy, or an in-network retail pharmacy.



WellSense members can 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 a 90-day supply of their medication with each refill.

Visit our Mail Order Pharmacy page for more details.