Prior authorization for provider-administered drugs

Select medications are Medical Benefit Only (MBO), meaning the drug is available through a health care professional who administers the drug or in an outpatient setting.

• Check the MassHealth Drug List or the MassHealth ACO/MCO Drugs Restricted to the Medical Benefit list to see if the medication is MBO.

1. Review the WellSense Preferred HCPCS Drug List for Massachusetts
2. For drugs on this list, select the WellSense drug specific PA form below and submit the request to WellSense via fax to 866-536-7185

• Asthma Monoclonal Antibodies Medical PA Form
• Compliment Inhibitors Medical PA Form
• Erythropoiesis Stimulating Agents Medical PA Form
• Filgrastim Products Medical PA Form
• Infliximab Products Medical PA Form
• Rituximab Products Medical PA Form

• Requesting online through an ePA portal
  • CoverMyMeds
  • ExpressPath
  • Surescripts

• Faxing to 833-951-1680
  • PA forms are available on the MassHealth Drug List
• Calling us at 877-417-1822 

1.    Review the WellSense Preferred HCPCS Drug List for Massachusetts
2.    For drugs on this list, select the WellSense drug specific PA form below and submit the request to WellSense via fax to 866-536-7185

• Asthma Monoclonal Antibiodies Medical PA Form
• Compliment Inhibitors Medical PA Form
• Erythropoiesis Stimulating Agents Medical PA Form
• Filgrastim Products Medical PA Form
• Infliximab Products Medical PA Form
• Rituximab Products Medical PA Form

3.    For all other drug codes, submit a PA by

• Requesting online through an ePA portal
  • CoverMyMeds
  • ExpressPath
  • Surescripts

• Faxing a general form below to 833-951-1680
  • Standard Medication Prior Authorization Form
  • Chemotherapy and Supportive Care Prior Authorization Request Form
  • Hepatitis C Prior Authorization Form
  • Synagis Prior Authorization Form

• Calling us at 877-417-0528

WellSense partners with Care Continuum (CCUM) to manage prior authorizations for medical drugs when administered by a health care professional or in an outpatient setting.

For drug codes requiring authorization, submit requests to CCUM

• Online through evicore.com
• Fax PA to 833-812-0687
• Call CCUM at 866-716-8338

1. Review the WellSense Preferred HCPCS Drug List for New Hampshire
2. For drug codes on this list, select the WellSense drug specific PA form below and submit the request to WellSense via fax to 866-536-7185
   • Actemra Medical PA Form
   • Asthma Monoclonal Antibodies Medical PA Form
   • Bevacizumab Products Medical PA Form
   • Cimzia Medical PA Form
   • Compliment Inhibitors Medical PA Form
   • Entyvio and Ilumya Medical PA Form
   • Erythropoiesis Stimulating Agents Medical PA Form
   • Filgrastim Products Medical PA Form
   • GnRH Agents Medical PA Form
   • Infliximab Products Medical PA Form
   • Orencia Medical PA Form
   • Pegfilgrastim Products Medical PA Form
   • Rituximab Products Medical PA Form
   • Simponi Aria Medical PA Form
   • Stelara Medical PA Form
   • Trastuzumab Products Medical PA Form
3. For all other drug codes, submit a PA by
   • Requesting online through an ePA portal
     • CoverMyMeds
     • ExpressPath
     • Surescripts

• Faxing a PA to 833-951-1680
• Calling us at 877-417-1839

WellSense partners with Care Continuum (CCUM) to manage prior authorizations for medical drugs when administered by a health care professional or in an outpatient setting.

For drug codes requiring authorization, submit requests to CCUM

• Online through evicore.com
• Fax PA to 833-812-0687
• Call CCUM at 866-716-8338