Prior Authorization

How to Submit Medication Prior Authorization Requests

New Coverage Review Process starting January 1, 2021 through our new Pharmacy Benefits Manager, Express Scripts.

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 complete the General Medication Request form.
  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 at 877-957-1300 or email us with questions about guidelines, submitting forms, or to request a printed version of any guideline or form.

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Community Mental Health Center Providers Only

Prior Authorization requirements for Behavioral Health Medications for CMHC providers in NH:

Other Drug Exceptions

Use the forms below to request a prior authorization for drugs not found in our formulary, newly marketed drugs, brand-name drugs or for quantity limit exceptions.