Prior Authorization Forms

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.

find prior authorization forms and criteria

Once you locate the drug, click the "More Info" link or the PA icon next to the drug to see the criteria and the form.

If the request meets criteria, Well Sense Health Plan will cover the drug and if denied, the member and the authorized appeal representative have the right to appeal. Please review clinical guidelines before submitting prior authorization requests.

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.

Search Covered Drugs

Enter a drug by name

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.

Contact Us

For questions about guidelines, submitting forms, or to request a printed version of any guideline or form, call 877-957-1300