Prior Authorizations

Request prior authorization for a medication

If you believe that it is medically necessary for a member to take a medication excluded by our pharmacy program and you have followed the procedures required by our pharmacy programs, you may request a coverage review. Select the member's plan below to get started.

Here is our current prior authorization (coverage review) process:

  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 877-417-1822 for MassHealth members or 877-417-0528 for Qualified Health Plan members. Or, you can submit the appropriate Standard Medication Prior Authorization Form: MassHealth
  4. As always, please view our Pharmacy Policies before submitting your coverage review requests.
Medical Benefit Drug Review for select drugs

Here is our current prior authorization (coverage review) process for six select Medical Drug policies:

  • Check the Massachusetts Medicaid and Qualified Health Plan Policy Topics and Covered HCPCS Drug Code List to see if a prior authorization is required for the medication, and associated J-code, you are requesting.
  • If you believe it is medically necessary for a member to take a medication that is not covered by our medical benefit program, you may submit a coverage review request via:
    • Fax by submitting the appropriate form below to (866) 539-7185
    • Phone by contacting 877-417-1822 for MassHealth members or 877-417-0528 for Qualified Health Plan members.
  • As always, please view our Medical Drug Policies before submitting your coverage review requests.

Medical Benefit Drug Review PA forms (for select drugs)
For providers of our Senior Care Options members: Vaccines are covered under both Medicare Part B and Part D. Learn more about vaccine coverage.

Contact us with questions about guidelines, submitting forms, or to request a printed version of any guideline or form.

Here is our current prior authorization (coverage review) process:

  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 877-417-1822 for MassHealth members or 877-417-0528 for Qualified Health Plan members. Or, you can submit the appropriate Standard Medication Prior Authorization Form: Qualified Health Plan
    MassHealth
  4. As always, please view our Pharmacy Policies before submitting your coverage review requests.
Medical Benefit Drug Review for select drugs

Here is our current prior authorization (coverage review) process for six select Medical Drug policies:

Other Drug Exceptions

Use the forms below to request a prior authorization for a newly marketed drug, a brand-name drug, or for quantity limit exceptions.

Contact us with questions about guidelines, submitting forms, or to request a printed version of any guideline or form.

Review clinical criteria and submit a prior authorization if necessary.

BMC HealthNet Plan members and providers can search the WellSense Senior Care Options Formulary for coverage of specific medications. If the provider feels that it is medically necessary for a member to take a medication excluded by our pharmacy program, he/she may submit a prior authorization request to the Plan by fax or online submission using the appropriate form below.

  • 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.

Please review clinical criteria before submitting prior authorization requests. Contact us with questions about guidelines, submitting forms, or to request a printed version of any guideline or form.

If you have a J-Code, please search our drug formulary by drug name. Not all services and procedures that require prior authorization may be listed. If you don't see a service or procedure in our matrix, please contact us.

 

Are vaccines for Senior Care Options covered under Medicare Part B or Part D?

Vaccines are covered under both Medicare Part B and Medicare Part D depending on the circumstances. In order to facilitate appropriate coverage and reporting of vaccines for Medicare enrollees in compliance with Medicare rules and regulations our Senior Care Options vaccine coverage is administered as follows:

Part B Vaccines:

  • Pneumococcal
  • Influenza
  • Hepatitis B for Moderate or High Risk Individuals
  • Vaccines used for treatment
*Part B vaccines can be administered by a physician in office and billed to WellSense or received at a network pharmacy  
 
Part D Vaccines:
  • Any vaccine not listed above, which is prescribed for preventive purposes (i.e. Zostavax)
  • A list of covered Part D vaccines is provided in the Plan formulary
Part D Vaccines have several options for coverage:
  • Pharmacy administration (Preferred Method) – Member obtains vaccine at a network pharmacy where it is administered by a pharmacist.
  • Provider administration of vaccine purchased at pharmacy (Alternative Method 1) – Physician supplies the member with a prescription for the vaccine. Member picks up the prescription from the pharmacy and brings back to the provider office for administration.
  • Provider administration with the vaccine supplied by the provider (Alternative Method 2) – Provider will need to use the reimbursement form to bill for Part D vaccines that are supplied and administered in office.
*It is anticipated that this method will be utilized by participating provider when there is considerable hardship due to member transportation or mobility restrictions that would preclude the member from getting the vaccine at a network pharmacy.