Prior Authorization

How to Submit Medication Prior Authorization Requests

If you believe that it is medically necessary for a member to take a medication restricted under one of our pharmacy programs, please: 

1. Check the formulary to see if prior authorization is required for a medication.
2. If you believe that it is medically necessary for a member to take a medication that is not covered by our pharmacy program: You may submit a coverage review request online through one of these ePA portals: Surescripts, CoverMyMeds, or ExpressPAth.
3. If you do not have access to an ePA system, you can contact 877-417-1839 to submit your request or submit your request by paper with the:
          Medication PA form (for Medicaid)
          Medication PA form (for Medicare Advantage)
4. Remember: Always view our Pharmacy Policies prior to submitting your coverage review request.
   
   

Once you submit your request:

• If the request meets criteria, Well Sense Health Plan will cover the drug
• If the request is denied, the member and the authorized appeal representative have the right to appeal the decision

Questions?

Call our Provider Service Center or email us with questions about guidelines, submitting forms, or to request a printed version of any guideline or form.