Pharmacy Policies

Pharmacy Policies

  1. Search the Well Sense Covered Drug List for coverage of specific medications.
  2. If you feel it is medically necessary for a member to take a medication that’s not covered, please submit a prior authorization request through an electronic PA portal for the fastest coverage determination.
  3. Be sure to check all clinical guidelines before submitting your coverage request. All pharmacy policies and criteria are listed in the searchable library below. Please use Google Chrome for the best user experience.

Search Pharmacy Policies

Type Title Language
ACEIs and ARBs (Policy NH9.601), Effective 01/01/2021 Pharmacy PA Forms
Acne and Rosacea Agents (Policy NH9.908), Effective 01/01/2021 Pharmacy PA Forms
Acterma (Tolicizumab)(Policy NH9.113), Effective 01/01/2021 Pharmacy PA Forms
Adakveo (Policy NH9.611), Effective 01/01/2021 Pharmacy PA Forms
Age & Quantity Limitation Program Policy (Policy NH9.050), Effective 01/01/2021 Pharmacy PA Forms
Anabolic Steroids (Policy NH9.907), Effective 01/01/2021 Pharmacy PA Forms
Antidepressants (Policy NH9.502), Effective 01/01/2021 Pharmacy PA Forms
Antiemetics (Policy NH9.905), Effective 01/01/2021 Pharmacy PA Forms
Antifungal Agents (Policy NH9.406), Effective 01/01/2021 Pharmacy PA Forms
Antineoplastic Agents (Policy NH9.700), Effective 01/01/2021 Pharmacy PA Forms
Anti-Obesity Medications (NH9.322), Effective 01/01/2021 Pharmacy PA Forms
Antipsychotics (Policy NH9.503), Effective 01/01/2021 Pharmacy PA Forms
Arcalyst (rilonacept) (Policy NH9.114), Effective 01/01/2021 Pharmacy PA Forms
Asthma-Allergy Monoclonal Antibodies (Policy NH9.109), Effective 01/01/2021 Pharmacy PA Forms
Benign Prostatic Hyperplasia (BPH) Medications (Policy NH9.805), Effective 01/01/2021 Pharmacy PA Forms
Benlysta (Belimumab) (Policy NH9.115), Effective 01/01/2021 Pharmacy PA Forms
Beta Blockers (Policy NH9.602), Effective 01/01/2021 Pharmacy PA Forms
Bile Acid Sequestrants (Policy NH9.910), Effective 01/01/2021 Pharmacy PA Forms
Botox (Policy NH9.209), Effective 01/01/2021 Pharmacy PA Forms
Brineura Policy NH9.301), Effective 01/01/2021 Pharmacy PA Forms
Buprenorphine and Naloxone Products (Policy NH9.504), Effective 01/01/2021 Pharmacy PA Forms
Calcitonin-Gene Related Peptide Antagonist (CGRP) (Policy NH9.205), Effective 01/01/2021 Pharmacy PA Forms
Cerdelga (Policy NH9.313), Effective 01/01/2021 Pharmacy PA Forms
Cholbam (NH9.308), Effective 01/01/2021 Pharmacy PA Forms
Cimzia (Certolizumab pegol) (Policy NH9.116), Effective 01/01/2021 Pharmacy PA Forms
Complement Inhibitors (Policy NH9.134), Effective 01/01/2021 Pharmacy PA Forms
Cosentyx (Secukinumab) (Policy NH9.117), Effective 01/01/2021 Pharmacy PA Forms
Crysvita (Policy NH9.324), Effective 01/01/2021 Pharmacy PA Forms
Cuvposa (Glycopyrrolate) (Policy NH9.203), Effective 01/01/2021 Pharmacy PA Forms
Cystic Fibrosis Agents (Policy NH9.100), Effective 01/01/2021 Pharmacy PA Forms
Daliresp (Policy NH9.111), Effective 01/01/2021 Pharmacy PA Forms
Diacomit (Stiripentol) (Policy NH9.201), Effective 01/01/2021 Pharmacy PA Forms
Duchenne Muscular Dystrophy Agents Policy (NH9.302), Effective 01/01/2021 Pharmacy PA Forms
Dupixent (Dupilumab) (Policy NH9.118), Effective 01/01/2021 Pharmacy PA Forms
Egrifta (NH9.304), Effective 01/01/2021 Pharmacy PA Forms
Enbrel (etanercept) (Policy NH9.119), Effective 01/01/2021 Pharmacy PA Forms
Enhertu (Policy NH9.706), Effective 01/01/2021 Pharmacy PA Forms
Entyvio (Policy NH9.120), Effective 01/01/2021 Pharmacy PA Forms
Erythropoiesis Stimulating Agents (Policy NH9.609), Effective 01/01/2021 Pharmacy PA Forms
Esbriet (Policy NH9.105), Effective 01/01/2021 Pharmacy PA Forms
Exforge / Exforge HCT (Policy NH9.623), Effective 01/01/2021 Pharmacy PA Forms
Gastrointestinal Agents (Policy NH9.804), Effective 01/01/2021 Pharmacy PA Forms
Gattex (Policy NH9.802), Effective 01/01/2021 Pharmacy PA Forms
Givlaari (NH9.321), Effective 01/01/2021 Pharmacy PA Forms
GnRH Agents (Policy NH9.703), Effective 01/01/2021 Pharmacy PA Forms
Growth Hormones (Policy NH9.325), Effective 01/01/2021 Pharmacy PA Forms
Hepatitis C (Policy NH9.404), Effective 01/01/2021 Pharmacy PA Forms
Hereditary Angioedema (Policy NH9.101), Effective 01/01/2021 Pharmacy PA Forms
Homozygous Familial Hypercholesterolemia (Policy NH9.603), Effective 01/01/2021 Pharmacy PA Forms
Humira (Policy NH9.121), Effective 01/01/2021 Pharmacy PA Forms
Hydroxyprogesterone Caproate (Policy NH9.800), Effective 01/01/2021 Pharmacy PA Forms
Ilaris (Policy NH9.122), Effective 01/01/2021 Pharmacy PA Forms
Immune Globulin (Policy NH9.110), Effective 01/01/2021 Pharmacy PA Forms
Impavido (Miltefosine) (Policy NH9.402), Effective 01/01/2021 Pharmacy PA Forms
Inbrija (Policy NH9.213), Effective 01/01/2021 Pharmacy PA Forms
Increlex (NH9.317), Effective 01/01/2021 Pharmacy PA Forms
Infliximab Products (Policy NH9.123), Effective 01/01/2021 Pharmacy PA Forms
Insomnia Agents (Policy NH9.211), Effective 01/01/2021 Pharmacy PA Forms
Kanuma (NH9.311), Effective 01/01/2021 Pharmacy PA Forms
Kineret (Policy NH9.124), Effective 01/01/2021 Pharmacy PA Forms
Korlym (NH9.303), Effective 01/01/2021 Pharmacy PA Forms
Krystexxa (Pegloticase) (Policy NH9.108), Effective 01/01/2021 Pharmacy PA Forms
Lambert Eaton Myasthenic Syndrome (Policy NH9.135), Effective 01/01/2021 Pharmacy PA Forms
Lucemyra (Policy NH9.501), Effective 01/01/2021 Pharmacy PA Forms
Mepsevii (NH9.316), Effective 01/01/2021 Pharmacy PA Forms
Metabolic Bone Disease Agents (NH9.318), Effective 01/01/2021 Pharmacy PA Forms
Methotrexate (Policy NH9.125), Effective 01/01/2021 Pharmacy PA Forms
Mozobil (Policy NH9.702), Effective 01/01/2021 Pharmacy PA Forms
Multiple Sclerosis (Policy NH9.212), Effective 01/01/2021 Pharmacy PA Forms
Myalept (NH9.307), Effective 01/01/2021 Pharmacy PA Forms
Mytesi (Policy NH9.903), Effective 01/01/2021 Pharmacy PA Forms
Narcolepsy (Policy NH9.208), Effective 01/01/2021 Pharmacy PA Forms
Natpara (NH9.309), Effective 01/01/2021 Pharmacy PA Forms
Non-Formulary Exceptions (Policy NH9.051), Effective 01/01/2021 Pharmacy PA Forms
Non-Preferred Blood Glucose Testing Products (NH9.320), Effective 01/01/2021 Pharmacy PA Forms
Non-Preferred PDL Drug Requests (Policy NH9.055), Effective 01/01/2021 Pharmacy PA Forms
Nplate (Policy NH9.106), Effective 01/01/2021 Pharmacy PA Forms
Nuedexta (Policy NH9.200), Effective 01/01/2021 Pharmacy PA Forms
Ocaliva (Obeticholic Acid) (Policy NH9.803), Effective 01/01/2021 Pharmacy PA Forms
Ofev (Policy NH9.133), Effective 01/01/2021 Pharmacy PA Forms
Olumiant (Policy NH9.132), Effective 01/01/2021 Pharmacy PA Forms
Opioids (Policy NH9.210), Effective 01/01/2021 Pharmacy PA Forms
Orencia (Policy NH9.126), Effective 01/01/2021 Pharmacy PA Forms
Osphena (Policy NH9.300), Effective 01/01/2021 Pharmacy PA Forms
Otezla (Policy NH9.127), Effective 01/01/2021 Pharmacy PA Forms
Oxbryta (Policy NH9.612), Effective 01/01/2021 Pharmacy PA Forms
Padcev (Policy NH9.707), Effective 01/01/2021 Pharmacy PA Forms
PCSK9 Inhibitors (Policy NH9.605), Effective 01/01/2021 Pharmacy PA Forms
Pegfilgrastim Agents (Policy NH9.622), Effective 01/01/2021 Pharmacy PA Forms
Pregabalin and Lyrica (Policy NH9.206), Effective 01/01/2021 Pharmacy PA Forms
Prestalia (Policy NH9.614), Effective 01/01/2021 Pharmacy PA Forms
Promacta (Policy NH9.107), Effective 01/01/2021 Pharmacy PA Forms
Pulmonary Hypertension (Policy NH9.600), Effective 01/01/2021 Pharmacy PA Forms
Pyrimethamine (Daraprim) (Policy NH9.400), Effective 01/01/2021 Pharmacy PA Forms
Rayaldee (NH9.314), Effective 01/01/2021 Pharmacy PA Forms
Reblozyl (Policy NH9.613), Effective 01/01/2021 Pharmacy PA Forms
Restaisis, Xiidra (Policy NH9.902), Effective 01/01/2021 Pharmacy PA Forms
Rho Kinase Inhibitors (Policy NH9.912), Effective 01/01/2021 Pharmacy PA Forms
Rinvoq (Policy NH9.102), Effective 01/01/2021 Pharmacy PA Forms
Rituximab (Policy NH9.704), Effective 01/01/2021 Pharmacy PA Forms
Samsca (NH9.319), Effective 01/01/2021 Pharmacy PA Forms
Savella (Policy NH9.202), Effective 01/01/2021 Pharmacy PA Forms
Signifor (NH9.306), Effective 01/01/2021 Pharmacy PA Forms
Simponi (Policy NH9.128), Effective 01/01/2021 Pharmacy PA Forms
Skyrizi (Policy NH9.140), Effective 01/01/2021 Pharmacy PA Forms
Spinal Muscular Atrophy (NH9.315), Effective 01/01/2021 Pharmacy PA Forms
Stelara (Policy NH9.129), Effective 01/01/2021 Pharmacy PA Forms
Step-Therapy Exceptions (Policy NH9.052), Effective 01/01/2021 Pharmacy PA Forms
Strensiq (NH9.312), Effective 01/01/2021 Pharmacy PA Forms
Sublingual Immunotherapy (SLIT) Medications (Policy NH9.104), Effective 01/01/2021 Pharmacy PA Forms
Synagis (Policy NH9.405), Effective 01/01/2021 Pharmacy PA Forms
Systemic Antibiotics (Policy NH9.403), Effective 01/01/2021 Pharmacy PA Forms
Taltz (Policy NH9.130), Effective 01/01/2021 Pharmacy PA Forms
Tarka (Policy NH9.624), Effective 01/01/2021 Pharmacy PA Forms
Tavalisse (Policy NH9.136), Effective 01/01/2021 Pharmacy PA Forms
Tepezza (Policy NH9.705), Effective 01/01/2021 Pharmacy PA Forms
Topical Immunomodulators (Policy NH9.103), Effective 01/01/2021 Pharmacy PA Forms
Topical Medications (MISC) (Policy NH9.906), Effective 01/01/2021 Pharmacy PA Forms
Tranexamic Acid (Policy NH9.801), Effective 01/01/2021 Pharmacy PA Forms
Trientine (Syprine) (NH9.310), Effective 01/01/2021 Pharmacy PA Forms
Viscosupplements (Policy NH9.909), Effective 01/01/2021 Pharmacy PA Forms
VMAT 2 Inhibitors (Policy NH9.204), Effective 01/01/2021 Pharmacy PA Forms
Vyndaqel, Vyndamax (Policy NH9.323), Effective 01/01/2021 Pharmacy PA Forms
Xeljanz (Policy NH9.131), Effective 01/01/2021 Pharmacy PA Forms
Xermelo (Policy NH9.701), Effective 01/01/2021 Pharmacy PA Forms
Xiaflex (Policy NH9.911), Effective 01/01/2021 Pharmacy PA Forms

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Community Mental Health Center Providers Only

Prior Authorization requirements for Behavioral Health Medications for CMHC providers in NH:

Other Drug Exceptions

Use the forms below to request a prior authorization for drugs not found in our formulary, newly marketed drugs, brand-name drugs or for quantity limit exceptions.