Drug transition policy

As a new or continuing member in our plan,

For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

If you are a new member who has been on a medication that is not on our formulary or needs a prior authorization, Fallon Community Health Plan ensures that you will be able to receive a 30-day supply of this medication within the first 90 days of your membership, as of your effective date of coverage. However, this 30-day supply will be considered a “transitional supply” of the medication. You will need to either have your provider prescribe a medication that is on our formulary or request a formulary exception.

When you pick up your prescription, the pharmacist may tell you that the prescription is a transitional supply. Within three business days, you will receive a notice from Fallon Community Health Plan confirming that you received a transitional supply. You also will receive information about how to work with your prescribing provider and Fallon Community Health Plan to identify alternative medications that are on Fallon Senior Plan’s formulary, an explanation of your right to request a formulary exception (that is, prior authorization approval to continue with the current medication), and the procedures for requesting a formulary exception.

If the pharmacist fills your transitional supply of medication for less than the prescribed amount (due to a plan limitation such as a quantity limit), Fallon Community Health Plan will allow refills of this medication up to the prescribed amount while you are pursuing a formulary exception.

Copayment amounts for transitional supplies are based on approved cost-sharing tiers and are consistent with cost-sharing amounts that Fallon Community Health Plan charges for non-formulary drugs approved under a coverage exception. If you receive extra help for your Medicare prescription drug coverage, the copayments for transitional supplies of medication will not exceed the current statutory maximum copayment amounts.