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Drug Tier Limit Notes
Abacavir 1   
Aber-Tuss HC1  
Abilify3PA  
Abilify Disc3PA  
Absorica 3   
Abstral 3PA 
Acanya 3PA  
Acarbose 1   
Accolate* 3 60 
Accu-Chek Control Soln 3  ST
Accu-Chek Lancet Device 2   
Accu-Chek Test Strips 3 150ST
Accuhist DM Pediatric*3  
Accuhist DM*3  
Accuhist LA*3  
Accuhist PDX*3  
Accuhist*3  
AccuNeb* 3   
Accupril*330 
Accuretic*330 
Accusure Insulin Syringe2  
Accutane*3  
Accuzyme SE3  
Accuzyme*3  
Acebutolol HCl1  
Aceon3  
Acetaminophen-Codeine1  
Acetaminophen-Codeine #21  
Acetaminophen-Codeine #41  
Acetasol HC1  
AcetaZOLAMIDE1  
Acetic Acid1  
Acetic Acid-Aluminum Acetate1  
Acetylcysteine1  
Acid Jelly 3   
Acidic Vaginal Jelly1  
Aciphex 3PA30ST
Aclovate* 3   
Actemra 3PA  
Acticin1  
Actigal* 3   
Actiq* 3PA  
Active Test3150 
Activella3  
Actonel 150mg* 3 1 
Actonel 35mg* 3 4 
Actonel 5mg, 30mg330 
ActoPlus Met XR 2 30 
ActoPlus Met* 3 60 
Actos* 3 30 
Acuflex3  
Acular3  
Acular LS3  
Acular PF3  
Acuvail 0.45% 3   
Acyclovir1  
Acyclovir ointment 1PA  
Aczone 3PA  
Adalat CC* 3   
Adapalene 1   
Adcirca 3PA Specialty Pharmacy
Adderall XR* 3   
Adderall*3  
Addyi -  New to Market Policy
Adempas 3PA Specialty Pharmacy
Adevovir 1PA  
Adjustable Lancing Device2  
Adoxa Pak 1/100*3  
Adoxa Pak 1/150*3  
Adoxa Pak 2/100*3  
Adoxa*3  
Adrenaclick 3   
Adrenalin3  
Advair Diskus 3 60 
Advair HFA 3 1 
Advance Control Solutions 3  ST
Advance Test Strips 3 150ST
Advicor3  
Aero Otic HC1  
Aerobid3  
Aerobid-M3  
Aerohist3  
Aerohist Plus1  
AeroKid*3  
AeroSpan 3   
Afeditab CR 1   
Afinitor 3PA Specialty Pharmacy
Afrezza 3PA  
Agenerase2  
Aggrenox* 3   
Agrylin* 3PA  
AH-Chew1  
AH-Chew D*3  
AH-Chew II3  
AH-Chew Susp3  
Aimsco Insulin Syringe2  
Aimsco Insulin Syringe Mx-Com2  
Aimsco Ultra Thin Lancets2  
Airet1  
AK-Con1  
AK-Dilate1  
AK-Pentolate1  
AK-Poly-Bac1  
AK-Pred1  
AK-Tob1  
Akineton3  
Akne-Mycin2  
Akorn Balanced Salt1  
Akynzeo 3PA  
Ala-Cort1  
Ala-Hist 3   
Ala-Quin3  
Ala-Scalp3  
Alacol DM3  
Alamast3  
Alba-33  
Albalon*3  
Albatussin CF3  
Albatussin CF Pediatric3  
Albatussin DM Pediatric3  
Albatussin EX3  
Albatussin NN1  
Albatussin Pediatric Drops3  
Albatussin Pediatric Liqd1  
Albatussin Pediatric Syr3  
Albatussin SR3  
Albatussin SR F3  
Albenza3  
Albuterol Sulfate1  
Albuterol/Ipratrop Nebs 1   
Alcet3  
Alclometasone Dipropionate1  
Alcortin3  
Aldactazide*3  
Aldactone*3  
Aldara 3  48 pkt per year
Aldex G3  
Aldex*3  
Aldoclor 3   
Aldoril D303  
Aldoril D503  
Aldoril-15*3  
Aldoril-25*3  
Alecensa -  New to Market Policy
Alendronate 35mg, 70mg 1 4 
Alendronate 5, 10, 40 1 30 
Alesse (28)* 3  
Alfuzosin 1 30 
Ali-flex1  
Alinia3  
Alkabel-SR1  
Alkeran3  
Allclenz3  
Allergen1  
AllerScript3  
Allersol1  
Allerx3  
Allerx DF3  
Allerx Dose Pack3  
Allerx-D*3  
Allfen3  
Allfen C3  
Allfen Jr*3  
Allfen-DM*3  
Allopurinol1  
Almotriptan 1 6 
Alocril3  
Alomide3  
Alora38 
Alosetron 1PA60 
Alphagan P 0.1% 2   
Alphagan P 0.15%* 3   
AlphaTrex1  
Alprazolam1  
Alprazolam Intensol3  
Alprazolam XR*130 
Alrex2  
Alsuma 3 2ST
Altabax 3   
Altace3  
Altafrin1  
Altavera 1  ACA Preventive Service $0
Altex-PSE1  
Altoprev3  
Aluminum Chloride Hexahydrate1  
Alupent3  
Alvesco 3PA  
Alycen 1  ACA Preventive Service $0
Amantadine HCl1  
Amaryl*3  
Ambi 1000/551  
Ambi 45/8001  
Ambi 45/800/301  
Ambi 5/15/1003  
Ambi 60/580*3  
Ambi 60/580/30*3  
Ambi 80/7001  
Ambi 80/700/401  
Ambi 80/7801  
Ambi 80/780/401  
Ambien CR* 3PA9 
Ambien* 3 30 
Ambifed-G3  
Ambifed-G DM3  
Amcinonide Crm, Lotn 1   
Amcinonide Oint 3   
Amdry-C1  
Amdry-D1  
Amerge* 3PA9 
Americaine Anesthetic3  
Americet1  
Amerifed3  
Amerifed DM3  
Amerituss AD3  
Ames Gluco System2  
Ames Gluco System High Control3  
Ames Gluco System Low Control3  
Ames Gluco System Normal3  
Amethia 1  ACA Preventive Service $0
Amethia Lo 1  ACA Preventive Service $0
Amethyst 1  ACA Preventive Service $0
Ami-Tex LA1  
Amibid DM1  
Amicar*3  
Amidal1  
Amidrine1  
Amigesic1  
Amiloride HCl1  
Amiloride-Hydrochlorothiazide1  
Amino Acid Cervical1  
Amino-Cerv*3  
Aminobenzoate Potassium1  
Aminocaproic Acid1  
Aminophylline1  
Amiodarone HCl1  
Amitex PSE1  
Amitiza3PA  
Amitriptyline HCl1  
Amlodipine 1   
Amlodipine - atorvastatin 1 30 
Amlodipine - benazepril 1   
Amlodipine-Valsartan 1 30 
Amnesteem1  
Amoclan1  
Amoxapine 3   
Amoxicillin1  
Amoxicillin 400mg Chew 3   
Amoxicillin-Pot Clavulanate1  
Amoxil*3  
Amphetamine Salt Combo1  
Ampicillin1  
Ampyra 3PA Specialty Pharmacy
Amrix 3PA  
Amturnide 3PA  
Anabar 3   
Anacaine3  
Anadrol 3PA  
Anafranil*3  
Anagrelide HCl1PA  
Analpram-HC* 3   
AnaMantle HC Forte3  
AnaMantle HC*3  
Anaplex DM*3  
Anaplex DMX3  
Anaplex HD*3  
Anaprox DS*3  
Anaprox*3  
Anaspaz*3  
Anastrozole 1   
Ancobon* 3   
Andehist DM NR1  
Andehist NR1  
Androderm330 
AndroGel 3   
AndroGel Pump3  
Android3  
Androxy3  
Anestacon1  
Anestafoam 3   
Anexsia*3PA  
Anextuss1  
Angeliq3  
Anolor 3001  
Anoro Elipta 3   
Ansaid*3  
Antabuse* 3   
Antara* 3  ST
Anthralin1  
Anti-Spas1  
Anti-Stick Insulin Syringe2  
Antiben1  
Antibiotic Ear1  
Antipyrine-Benzocaine1  
Antispasmodic1  
Antivert*3  
Anucort-HC1  
Anusol-HC*3  
Anzemet23 
APAP Isomethheptene Caff 1   
ApexiCon1  
Apexicon E Crm 3   
ApexiCon E Oint 1   
Aphrodyne1  
Aphthasol3  
Apidra Cartridge3PA  
Apidra Vial 3PA  
Aplenzin 3PA  
Apokyn 3PA Specialty Pharmacy
APOP 3   
Apraclonidine 0.5% 1   
Apri 1  ACA Preventive Service $0
Apriso 2   
Aptensio 3   
Aptiom 3PA  
Aptivus3  
Aquabid-DM1  
Aquachloral3  
Aquatab C*3  
Aquatab D*3  
Aquatab DM*3  
Aralen*3  
Aranelle 1  ACA Preventive Service $0
Aranesp 3PA Specialty Pharmacy
Arava* 3   
Arcalyst 3PA Specialty Pharmacy
Arcapta 3 30 
Aricept ODT 3   
Aricept* 3   
Arimidex* 3   
Aripiprazole tabs 1PA  
Aristocort A*3  
Arixtra* 3  Limit 14 day supply
Armour Thyroid* 3   
Arnuity Elpt Inhaler 3   
Aromasin* 3   
Arthrotec 50* 3   
Arthrotec 75* 3   
Asacol 2   
Asacol HD 2   
Ascensia Control Solns 3  ST
Ascensia Lancets 2   
Ascensia Test Strips 3 150ST
Ascomp-Codeine1  
Asmanex 120 Metered Doses3  
Asmanex 14 Metered Doses3  
Asmanex 30 Metered Doses3  
Asmanex 60 Metered Doses3  
Asmanex HFA 3   
ASP 300/200/201  
Aspirin 1  ACA Preventive Service $0
Aspirin EC 1  ACA Preventive Service $0
Aspirin-Codeine #31  
Aspirin-Codeine #41  
Assure Control Solns 3  ST
Assure Test Strips 3 150ST
Astagraf XL 3  
Astelin* 3   
Astepro* 3   
At Last Control Solution 3  ST
At Last Lancets2  
At Last Test Strips 3 150ST
Atacand HCT* 3   
Atacand* 3   
Atamet1  
Atarax*3  
Atelvia* 3 4 
Atenolol1  
Atorvastatin 1 45 
Atovaquone 1   
Atovaquone / Proguanil 1   
Atripla 3   
Atuss MR*3  
Atuss MS*3  
Atuss NX*3  
Atuss-12 DM3  
Atuss-12 DX3  
Aubagio 3PA  
Aubra 1  ACA Preventive Service $0
Aug Betamethasone Dipropionate1  
Augmentin ES-600*3  
Augmentin XR3  
Augmentin*3  
Aurobiotic-HC1  
Aurodex1  
Auroguard1  
Aurora Healthcare Lancets2  
Auryxia 3PA Specialty Pharmacy
Auto-Lancet2  
Auto-Lancet Mini2  
Auto-Lancets2  
AutoLancet2  
Autolet2  
Autolet 22  
Autolet II Clinisafe2  
Autolet Lancing Device2  
Autolet Lite Clinisafe2  
Autolet Lite Starter Pack2  
Autolet Mini2  
Autopen2  
Auvi-Q 3   
Av-Phos Neutral 1   
Avalide3  
Avandamet3  
Avandaryl3  
Avandia3  
Avapro3  
Avar Cleanser1  
Avar Green3  
AVAR-e Emollient1  
AVAR-e Green1  
Avar-E LS 3   
AVC Vaginal3  
Avelox 3   
Avelox ABC Pack2  
Aventyl*3  
Aviane 1  ACA Preventive Service $0
Avinza* 3   
Avita 1PA PA if >26 eff 09/10
Avodart* 3   
Avonex 2  Specialty Pharmacy
Axert* 3 6 
Axid*3  
Axiron 3PA  
Axocet1  
Aygestin*3  
Azasan3  
Azasite 3  QL is 2.5ml per RX
Azathioprine1  
Azelastine Soln 1   
Azelex3  
Azilect 3   
Azithromycin 1   

The drug formulary, which includes both generic and brand names, lists prescription medications covered by Fallon Community Health Plan. It is an alphabetical list by both generic and brand names of medications. Next to the medication name is the appropriate tier number, along with 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. Please see the legend below for a listing of codes and an explanation of each.

Self-injectable medications used in the home setting are included in this formulary. Injections given by health care professionals in a health care setting are not.

Please note: This list represents the FCHP 3-tier prescription drug formulary used for most of our commercial plans. It is subject to change at any time. Members participating in FCHP MassHealth or our Commonwealth Care type 1 plan should contact our Customer Service Department (1-800-868-5200 or TTY users, please call TRS Relay 711) with questions on prescription drug coverage.

Legend
PA Prior authorization is required. Your health care provider must contact FCHP to arrange this.
Limit Quantity limits may be set for certain drugs depending upon available safety data. For example, only nine tablets of drug X per 30 days.
New to market When a medication first becomes available, it falls under our "New to market" policy and is excluded from coverage. Our "New to market" policy ensures patient safety by allowing us adequate time for the development, review and approval of clinical criteria. We do have a process in place that allows us to quickly review provider requests for non-covered pharmaceuticals.
ST Step Therapy. In some cases, FCHP requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, FCHP may not cover Drug B unless you try Drug A first. If Drug A does not work for you, FCHP will then cover Drug B.
* Indicates that the drug is a brand-name drug for which a generic version may be available.