Pharmacy Programs

The Prior Authorization Program requires that WellSense members meet specific clinical conditions before a drug can be covered.

View Clinical Guidelines and Prior Authorization Forms

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.

View Clinical Guidelines and Prior Authorization Forms

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.

View Clinical Guidelines and Prior Authorization Forms

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.

View Clinical Guidelines and Prior Authorization Forms

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.

View Clinical Guideline

View Prior Authorization Forms

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.

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View Clinical Guidelines and Prior Authorization Forms

The Prescription Drug Monitoring Program (PDMP) identifies a member population at risk for inappropriate use of medications that have potential for abuse, including schedule II controlled substances and high risk non-controlled substances. Members are automatically enrolled into the program if they are identified through algorithms that incorporate pharmacy claims and medical service utilization data.

The program incorporates both automatic interventions and Clinical Pharmacist review of member cases for interventions depending on the specific algorithm triggered. All cases referred into the program by internal staff or Providers are evaluated by a Clinical Pharmacist. As part of the review process, the Clinical Pharmacist evaluates the member’s medical history including emergency room visits, patterns of medication use, and gaps in coordination of care among prescribers to determine the appropriate intervention(s) to be completed, if any.

Intervention actions may include direct provider communication, restriction of medication access through a single pharmacy and/or physician (physician group), as well as referrals to Fraud and Abuse for further evaluation. The goal of the program is to help health care providers be better informed of their patient medication use patterns, and promote proactive management to minimize the potential for medication misuse.

To learn more or to enroll a member, please call 888-566-0008 and ask to speak with a pharmacy representative.