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 Controlled Substance Management Program (CSMP), previously known as the Prescription Drug Monitoring Program or PDMP, is intended to prevent the 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 Service.
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.
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.
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