How to use the Fallon Senior Plan online drug formulary

Online drug formulary Q &A

First, you need to know what plan you are on or what plan you are considering joining. There are two types of Fallon Senior Plan enrollments: “individual” or “group.” Select “individual” if you have enrolled, or are looking to enroll, in Fallon Senior Plan directly through FCHP or if you are a prospect. Select “group” if you receive your benefits through your or your spouse’s current or former employer.

If you have selected “individual,” you will then need to choose a plan option from the drop down menu. For example, if you are a Fallon Senior Plan Standard Basic Rx member, you would select “Fallon Senior Plan Standard Basic Rx—$100/month” from the drop-down menu on the search page. If you are not yet a member, please select “prospect” from the drop-down menu.

If you have selected “group,” you will then need to choose which formulary you would like to search from the drop-down menu. If you are not sure which formulary to search, please contact your or your spouse’s benefits administrator for more information.

Searching

You may search for drugs on the formularies two different ways:

1. By drug class – if you are searching for all the drugs that are used for a specific purpose, e.g., antihistamines.
2. By drug name – if you are searching to find a particular drug by name, brand and/or generic, such as LIPITOR.

Once you have decided which way you would like to conduct your search, you may either type in the complete name or the first letter(s) of the drug in the text box, or choose the drug class from the drop down and then click “search.”

Understand the results

The results of your search will display in a table. This table will be an alphabetical list by both generic and brand name of medications. Next to the medication name is the drug class, appropriate tier number or copayment type (for Fallon Senior Plan Value 1 and Fallon Senior Plan Value 2) and any codes. The different codes describe important information, such as prior authorization requirements, which means your provider must contact FCHP for approval prior to prescribing certain medications. The legend below is an example of the list of codes and an explanation of each that may apply.

Legend:

Drug not found

If you are conducting a search and the drug you are searching for is not found, you should first contact Customer Service and ask if that drug is covered.

If you learn that Fallon Community Health Plan does not cover your drug, you have two options:

1. You may ask Customer Service to mail you a list of similar drugs that are covered by FCHP. When you receive the list, ask your provider to review it and to prescribe a similar drug that is covered by FCHP.
2. You may ask FCHP to make an exception to cover your drug. See below for information about how to request an exception.

Requesting an exception to the formulary

You can ask Fallon Senior Plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover your drug even if it is not on our formulary.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Fallon Senior Plan may limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
• You can ask us to provide a higher level of coverage for your drug. If your drug is in our highest tier that is subject to the tiering exceptions process, you can ask us to cover it at the cost-sharing amount that applies to drugs in the lowest tier that is subject to the tiering exceptions process instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug.

Generally, Fallon Senior Plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician’s supporting statement.