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 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 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 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 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.