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 on your behalf, or you can submit a request for yourself.

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.  If a drug falls into this group and may be medically necessary for you, your doctor can submit a request on your behalf, or you can submit a request for yourself.

The quantity limitation program limits the amount of specific medications 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 doctor can submit a request on your behalf, or you can submit a request for yourself.

The Medical Drug Management Program (MDM) requires that some prescriber-administered drugs meet specific clinical conditions before a drug can be covered.  These drugs include injectable and intravenous drugs administered by your doctor in either their office, or other facility. WellSense Health Plan partners with Care Continuum (CCUM) to manage the provider-administered drug program.

If a drug falls into this group and may be medically necessary for you, your provider can submit a prior authorization (PA) request on your behalf to CCUM, or you can start a request for yourself by calling CCUM at 877-817-4042.

The Food and Drug Administration (FDA) has determined certain generic drugs are therapeutically equivalent (AB-rated) to their brand counterparts. The mandatory generic substitution program requires a member to try an AB-rated generic drug before its brand counterpart would be covered.  If a drug falls into this group and may be medically necessary for you, your doctor can submit a request on your behalf, or you can submit a request for yourself.

New drugs are reviewed by our Pharmacy and Therapeutics Committee for safety and efficacy before they are added to the WellSense list of covered drugs. If a drug falls into this group and may be medically necessary for you, your doctor can submit a request on your behalf, or you can submit a request for yourself.

The specialty pharmacy program requires that some drugs be supplied by a specialty pharmacy. These drugs include oral, injectable and intravenous drugs that are often used to treat chronic (ongoing) conditions which require the additional expertise and support of a specialty pharmacy.  WellSense partners with the following specialty pharmacies to provide these drugs:

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

The prescription drug monitoring program is intended to prevent misuse of certain medications. Members are automatically enrolled in the program if their medical history meets program criteria. Healthcare providers can also request for members to be enrolled into the program. To learn more, contact Member Services.

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.

Learn how to enroll in our mail order pharmacy program.