WellSense uses a number of pharmacy programs to promote the safe and appropriate use of prescription drugs.
MassHealth and Qualified Health Plans
All drugs that belong to a pharmacy program have clinical guidelines (like current health condition) that must be met before the Plan will cover it. Drugs that belong to a pharmacy program are indicated on the WellSense Formulary.
If a provider feels that it is medically necessary for a member to take a drug managed under one of our programs, he/she may submit a request to WellSense using the appropriate Prior Authorization Form. WellSense will review the prior authorization request using the Medication Exception Process. If the request meets criteria, WellSense will cover the drug. If the request is denied, the member and the authorized appeal representative have the right to appeal the decision.
The Prior Authorization Program requires that WellSense members meet specific clinical conditions before a drug can be covered.
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.
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 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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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.