Pharmacy Policies

Providers

Pharmacy Policies

Search the Well Sense Covered Drug List for coverage of specific medications.
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.
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.