Prior authorization for medications

Request a PA for a Pharmacy Drug

  • Check the formulary and our pharmacy policies to see if a prior authorization is required for a pharmacy drug.
  • If prior authorization is required, select the member’s plan below for more information on how to submit a prior authorization.

  • Online through an ePA portal
  • To request a prior authorization form for a member, Request a Medical Exception
    • Upon receipt of your request, the PA form will be faxed to the requesting provider
    • Fax the completed prior authorization form to 833-951-1680
  • Call 877-417-1822 to initiate a prior authorization by phone

  • To request a prior authorization form for a member, Request a Medical Exception
    • Upon receipt of your request, the PA form will be faxed to the requesting provider
    • Fax the completed prior authorization form to 833-951-1680
  • Call 877-573-1929 to initiate a prior authorization by phone

  • Call 877-417-1839 to initiate a prior authorization by phone

Community Mental Health Center Providers Only
Prior Authorization requirements for Behavioral Health Medications for CMHC providers in NH:

Request a PA for a Medical (Provider-Administered) Drug

Select drugs are available under the Medical Benefit.  

  • For MassHealth only, select medications are Medical Benefit Only (MBO), meaning the drug is available through a health care professional who administers the drug or in an outpatient setting.
  • For New Hampshire Clarity Plans and Medicare Advantage Plans (HMO/PPO) only, WellSense partners with Care Continuum (CCUM) to manage prior authorizations for select medical drugs when administered by a health care professional or in an outpatient setting.
    • See below for more details on submitting a prior authorization request for New Hampshire Clarity and Medicare Advantage members.
Check the HCPCS tool to see if prior authorization is required for a provider-administered drug.
  • Please note, the HCPCS tool is not a comprehensive list of all drug codes. If a drug code is not on the HCPCS tool, no authorization is required for the drug itself when provider-administered (other benefit coverage rules may apply).
  • If prior authorization is required, select the member’s plan below for more information on how to submit a prior authorization.

  1. Review the WellSense Preferred HCPCS Drug List for Massachusetts
  2. For drugs codes on this list, select the WellSense drug specific PA form below and submit the request to WellSense via fax to 866-536-7185
  3. For all other drug codes, submit a PA by  
    • Faxing to 833-951-1680
    • Calling us at 877-417-1822 

 

1.    Review the WellSense Preferred HCPCS Drug List for Massachusetts 
2.    For drugs codes on this list, select the WellSense drug specific PA form below and submit the request to WellSense via fax to 866-536-7185

3.    For all other drug codes, submit a PA by

  1. For drug codes that the HCPCS Tool indicate are managed by Care Continuum (CCUM), submit requests
    • Online through evicore.com
    • Fax  PA to 833-812-0687
    • Call CCUM at 866-716-8338
  2. For drug codes that the HCPCS Tool indicates are Pharmacy Managed, submit requests
  3. For drug codes that the HCPCS Tool indicates are managed by other means (i.e. Medically Necessary or Gene Therapy), submit requests
    o    Online through HealthTrio
    o    Call us at 855-833-8122
  •  

  1. Review the WellSense Preferred HCPCS Drug List for New Hampshire
  2. For drug codes on this list, select the WellSense drug specific PA form below and submit the request to WellSense via fax to 866-536-7185
  3. For all other drug codes, submit a PA by
    • Faxing a PA to 833-951-1680
    • Calling us at 877-417-1839

For drug codes requiring authorization, submit requests to Care Continuum (CCUM)
  1. Online through evicore.com
  2. Fax  PA to 833-812-0687
  3. Call CCUM at 866-716-8338