Pharmacy Programs

Our pharmacy programs promote the safe and appropriate use of prescription drugs. Drugs that belong to a program have clinical guidelines that must be met before we will cover the medication (for example, an evaluation of the member’s current health condition). Drugs that belong to a pharmacy program may be found in the Formulary.

If you feel that it is medically necessary for a member to take a drug managed under one of our programs, you may submit a request to Well Sense Health Plan using the appropriate prior authorization form.

WellSense will review the prior authorization request using the applicable clinical guideline. 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.

Pharmacy Prior Authorization Program

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

Step Therapy Program

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.

Generic Substitution Program

The 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-name drug is medically necessary

New-to-Market Medication Program

Well Sense Health Plan 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.

Quantity Limitation Program

The Quantity Limitation Program ensures the safe and appropriate use of certain medications by defining the specific amount that can be dispensed at one time. Quantities greater than the specified amount require prior authorization for coverage.

Specialty Pharmacy Program

The Specialty Pharmacy Program requires that certain drugs be supplied by a specialty pharmacy. These drugs include injectable, intravenous and oral drugs that are often used to treat chronic conditions, like Hepatitis or Crohn’s disease. Storing and dispensing these drugs generally requires special expertise and facilities. In addition, specialty pharmacies have extensive training and detailed knowledge to provide personalized support to members and providers.

Cornerstone Health Solutions: 1-844-319-7588

Prescription Drug Monitoring Program

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 a clinical pharmacist’s 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 as well as referrals to fraud and abuse for further evaluation. The goal of the program is to assist healthcare providers to be better informed of their patients' medication use patterns, and promote proactive management to minimize the potential for medication misuse.

To learn more or to enroll a member, please the Provider Services line at 877-957-1300 and select the pharmacy option.