Prescriptions Not Covered

What if one of my prescriptions is not covered?

Call Well Sense Member Services at 877-957-1300 and give them the name of the drug. They'll tell you if there are any restrictions on that drug, and what to do next.

Why wouldn't a prescription drug be covered?

Reasons might include:

  • If a brand-name drug has a generic version, your doctor must prescribe the generic drug (drugs with the same ingredient as a brand-name drug, but with a different name) when available
  • If a drug might not be safe or effective at a certain dose or strength. In order to ensure that you get a safe and effective dose of a prescription drug, we may set limits on is quantity and dose strength
  • If a drug is newly approved by the FDA. Your doctor may may need to get prior approval from us before prescribing a newly marketed drug
  • If a drug should only be used for certain medical conditions, we may ask your doctor to provide additional medical information before we cover a non-preferred drug
  • If you have Medicare Part D coverage, only drugs that are excluded under the Medicare Part D  program will be covered by your Well Sense pharmacy benefit. All other drugs will need to be obtained through your Medicare Part D plan. Not sure if you have Medicare Part D? Call 1-800-Medicare (1-800-633-4227).

May I request an exception?

Yes. Talk to your doctor about requesting prior approval from us to get an exception.

How does my doctor get an exception (also called prior authorization) for me?

  1. Ask your doctor to contact us and request a prior authorization (an exception) explaining why you need the medication.
  2. After we receive the statement, we will send your doctor a decision on your exception request. If we need more information on your doctor's request, it could take longer to get a decision.

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2021 Drug List

2021 Pharmacy Changes

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New for 2021! Starting in January we're updating our Pharmacy Benefits to help improve your overall member experience. View our member FAQs for more information.

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What's the difference between a generic and brand-name drug?

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When a company makes a new drug for the first time, they are the only ones who can sell it for a certain number of years. This is a brand-name drug. After that time, other companies can make and sell the same drug under a different name, making it a generic drug.