Request Prior Authorization for a Medication

Prior Authorization and Clinical Guidelines

  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 submit your request by paper with the:

    Medication PA form (for Medicaid)
    Medication PA form (for Medicare Advantage)
  4. Remember: Always view our Pharmacy Policies prior to submitting your coverage review request.
Medical Benefit Drug Review for select drugs

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

  1. Check the WellSense Health Plan Policy Topics and Covered HCPCS Drug Code List to see if prior authorization (or coverage review) is required for a medication, and associated J code, you are requesting.
  2. If you believe that 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 or by phone by contacting 877-417-1839.
  3. Always view our Pharmacy Policies prior to submitting your coverage review request.