GENERAL

Wellfleet Rx is a specialized pharmacy benefits solution from Wellfleet, an innovative provider of insurance solutions. Wellfleet Rx helps us achieve our mission of protecting people against risk throughout every stage of life — ensuring pharmacy needs are covered via customized and member-driven benefits. To deliver Wellfleet Rx, we’ve partnered with Kroger Prescription Plans and Express Scripts as pharmacy benefit managers (PBMs). The PBM administers the pharmacy portion of your healthcare benefits, as defined by your Wellfleet Student Health plan. 

Visit our Contact Us page for contact information.

PHARMACY NETWORK

Once you sign in to your account, it is easy to find a pharmacy that is part of your pharmacy network. Click on the Find a Pharmacy or pharmacy search option on the home page and fill in the search fields. Simply enter your city and state or zip code. The Pharmacy Locator will display pharmacies that match your search.

Participating pharmacies can fill prescriptions for covered medications at the lowest cost. Participating pharmacies agree to set prices for products and services covered by your plan.  See “How do I find a participating pharmacy?”

Out-of-network coverage is defined by your Wellfleet Student health plan. Choosing an out-of-network pharmacy may mean that your drug may not be at the lowest price possible. The pharmacy network includes a broad array of high-quality pharmacies that can provide you with cost effective medications. 

Your pharmacy benefit may include some products that are called “specialty” medications. Specialty medications are high-cost prescription drugs used to treat complex conditions, such as Cancer, Multiple Sclerosis, Hepatitis C, and Rheumatoid Arthritis. Many specialty drugs are injected and require special handling, administration, and/or monitoring.

If your ID card lists Wellfleet Rx/KPP with BIN 012882, Kroger Specialty Pharmacy is the preferred provider of specialty medications through Wellfleet Rx/KPP. Kroger Specialty Pharmacy helps members manage their complex drug therapies by ensuring reliable delivery and comprehensive drug and disease education and counseling. Enrollment in the specialty pharmacy program is easy.  Members can call the Customer Service Center toll-free at 1-888-800-7828 to get started.

If your ID card lists Wellfleet Rx/ESI with BIN 003858, Accredo is the preferred provider of specialty medications through Wellfleet Rx/ESI. Accredo helps members manage their complex drug therapies by ensuring reliable delivery and comprehensive drug and disease education and counseling. Enrollment in the specialty pharmacy program is easy.  Members can speak to a patient-care representative toll-free at 1-877-895-9697 to get started.

If your ID card lists Wellfleet Rx/KPP with BIN 012882 and your plan covers medications through mail order, prescriptions can be obtained through the mail via Postal Prescription Services (PPS). Refer to your plan document to determine if your plan covers medications through mail order. To have a current prescription filled with PPS, you may contact your physician and have them send a new prescription to any PPS pharmacy or you are able to have PPS transfer-in any current Prescription by calling them at 1-800-552-6694 and providing your current pharmacy’s information. Online access to patient information and prescription ordering is also available through ppsrx.com.

If your ID card lists Wellfleet Rx/ESI with BIN 003858 and your plan covers medications through mail order, prescriptions can be obtained through the mail via Express Scripts Pharmacy. Refer to your plan document to determine if your plan covers medications through mail order. To have a current prescription filled with Express Scripts Pharmacy, you may contact your physician and have them send a new prescription to Express Scripts Pharmacy. You may also contact Express Scripts Pharmacy at 1-877-640-7940 if you would prefer Express Scripts Pharmacy to contact your physician for a new prescription. Online access to patient information and prescription ordering is also available through express-scripts.com.

Formulary & Pharmacy Benefit

A formulary is a list of prescription drugs may be covered by a PBM or health plan. Your formulary provides detailed information on what drugs may be covered, but actual coverage is based on your plan design and whether limitations and requirements have been met. Limitations and requirements are noted within the formulary. Refer to your plan documents for applicable coverage exclusions. 

Student Formulary Features

40+ free generic options

In addition to the $0 medications available under ACA preventive requirements, the Wellfleet Rx Student Formulary offers 40+ antibiotic, dermatology, and behavioral health medications at no copay*.  Refer to the “Zero Cost Generics” section of the Student Formulary for the full list of medications covered under this program. We encourage you to share this list with your prescriber if you are receiving a medication in one of the categories featured to determine if a zero cost option may be appropriate for your treatment.

*Zero Cost Generics program may vary by school or may not be available to certain schools.  See applicable Student Formulary for more details.  If there is no “Zero Cost Generics” section included in the Student Formulary applicable to your plan, this program is unavailable.

Helping you avoid high-cost generic drugs

Preferred generics are available under the tier 1 of the Wellfleet Rx Student Formulary. Compared to their higher cost generic counterparts, the preferred generics have been reviewed for similar efficacy and clinical indications and similar side effect profiles.  To help allow students and their providers to make informed decisions and drive them toward preferred generics, some high cost generics may be placed in a higher formulary tier and be associated with higher copays. Students are encouraged to discuss preferred generic alternatives with their providers when prescribed a non-preferred generic.  Pharmacies will receive point-of-sale messaging and students will receive letters when non-preferred generics are prescribed to provide education on preferred, lower cost alternatives.

Preventing opioid abuse

The STOP program from Wellfleet Rx promotes safety and appropriateness before opioids are dispensed through improved drug utilization controls.  The Wellfleet Rx Student Formulary includes utilization management requirements and limitations on opioids to prevent excessive opioid dispensing and unnecessary long-term opioid use.  Formulary controls include days supply limitations, prior authorizations on refills, and cumulative dose threshold reviews.

Once you log in, you can see how much a medicine will cost you by clicking on either the Benefit Highlights/Benefits Overview or Drug Price Check/Price a Medication link found in the menu bar.

Benefit Highlights/Benefits Overview will show your current copay amounts and, if it applies to you, your deductible and maximum out-of-pocket expenses.

Drug Price Check/Price a Medication will give you tier, brand and generic information, as well as prices based on the pharmacy you consider using.

**Note that you will need to be a registered user to view these tools.

Once you log in to your account, you can see if a medicine is covered by your pharmacy benefit by clicking on the Drug Price Check/Price a Medication link found in the menu bar. Drug Price Check/Price a Medication will tell you the formulary status of each drug, and it will allow you to see if there are other drugs in a certain drug class that may be available for a lower cost.

Drug Price Check/Price a Medication also can provide you with a cost estimate for a certain drug.

Your pharmacy benefit may not cover all medications prescribed by your provider. Exclusions may include certain prescription medications, over-the-counter (OTC) medications, or any drug products used for weight loss or other cosmetic purposes.

To see if a medication is covered by your pharmacy benefit, click on the Drug Price Check/Price a Medication link located in the menu bar. Drug Price Check/Price a Medication will indicate if a medication is not covered.

For more detailed information, refer to your plan documents.

Yes. When you fill your prescription at a pharmacy, the pharmacist will use their best judgment to decide if any of the drugs you are filling has an interaction with any of the drugs you are taking.

If you use your benefit card when you fill your prescription, Wellfleet Rx will also receive information about your medication. Our system will also notify the pharmacist of potential drug interactions based on the data that is in our system at that time. Wellfleet Rx can alert the pharmacist immediately if there are any potential interactions with the medication you are filling.

Yes. If you are traveling within the United States and you need to fill a prescription, you can use your card at any pharmacy in your pharmacy network to fill a prescription. To find a pharmacy that is part of your pharmacy network, click on the Pharmacy Locator link that is in the menu bar and enter your criteria.

Yes. If you are traveling within the United States and you need to fill a prescription, you can use your card at any pharmacy in your pharmacy network to fill a prescription. To find a pharmacy that is part of your pharmacy network, click on the Pharmacy Locator link that is in the menu bar and enter your criteria.

Your pharmacy benefit card will not be accepted when traveling outside the United States.  It is important that you plan in advance to ensure you have enough medication to last the duration of your travel.  In order to obtain additional medication prior to your next eligible refill or for a quantity exceeding days supply limitations under your plan, you can request a vacation override by calling Wellfleet Rx at the phone number on your ID card. Prior to requesting a vacation override, check to ensure your prescription has enough refills remaining to last the duration of your trip.

Yes. There may be additional limits on certain drugs, even when they are covered by your plan. These rules may include the amount you can fill at one time (quantity limit), a maximum age for receiving a drug, or the gender of a person taking the drug. Other rules may add additional steps to see if you qualify for approval, such as prior authorization or step therapy. For more information on these, see the Drug Price Check/Price a Medication tool.

Your plan may require specific drugs to be reviewed against a set of criteria to determine if the plan will cover the medication. The Prior Authorization process looks at whether or not a member meets the criteria for coverage.

For questions regarding the status of a prior authorization, you can call Wellfleet Rx at the number on your ID card.  

You will receive a letter explaining why the prior authorization or medical exception request was denied. Under certain circumstances, you may have the right to appeal denial decisions. The letter will explain how to file an appeal.

Certain drugs are considered dangerous by the federal government because they are more likely to be abused or cause addiction. These drugs, known as controlled substances, and are divided into categories. These drugs range from illegal street drugs (C1) to drugs with decreasing potential for abuse (C2 through C5). Prescriptions that have narcotics or amphetamines are often considered C2 controlled substances.

If your ID card lists Wellfleet Rx/KPP with BIN 012882: Once you log in, you can access your pharmacy claims history by clicking on the PersonalHealthRx link found in the menu bar. Enter the prescriptions report section and select your criteria.

Through PersonalHealthRx, you can view and print the data for a specified time period. The report will have areas for drug name, fill date, prescription number, quantity, days supply, copay cost, plan paid amount, prescribing physician and dispensing pharmacy. Pharmacy claims history can be provided to your doctor if needed. Note that you will need to be a registered user to log in.

If your ID card lists Wellfleet Rx/ESI with BIN 003858: You can access your prescription claims and history on express-scripts.com by selecting the Claims & Balances link found in the Prescriptions drop down menu.  The claims information display shows RX number, date of service, drug information, where the prescription was filled and plan paid vs. member paid amounts.  Additional prescription history details are found by clicking the View prescription history details link associated with the claim.  You can also download the information from this page for tracking purposes.  You must be registered on the site to view this information.

If you paid for a prescription medication without attempting to process it through your insurance, you should contact the pharmacy to see if they can reprocess your claim through insurance and provide you with a refund.  Most pharmacies can accommodate this request within 1-2 weeks from when the medication was dispensed.  If the pharmacy is unable to reprocess the claim, you can submit a reimbursement request to Wellfleet Rx by following the instructions in the Direct Member Reimbursement form available on the Students page. Once you have completed the form, you may email, fax, or mail it with a copy of your prescription receipt(s) to the contact information located within the form. Approved claims are generally paid within two weeks. A check will be mailed directly to you.

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Wellfleet is the marketing name used to refer to the insurance and administrative operations of Wellfleet Insurance Company, Wellfleet New York Insurance Company, and Wellfleet Group, LLC. All insurance products are administered or managed by Wellfleet Group, LLC. Product availability is based upon business and/or regulatory approval and may differ among companies.