Pharmacy exception process

Sometimes, your drug may not be on our formulary.  If the drugs on our formulary are not appropriate for you, there is a formulary exception process available. This process follows the standard Prior Authorization process, except where noted below.

Non-covered items 

Non-Formulary: 
Medications not on the formulary are considered non-formulary and are not covered. If your provider feels that the medications on our formulary are not appropriate for your condition, there is a formulary exception request process available. Your prescriber must support the request by providing clinical information and a statement that provides justification for supporting the need for the non-formulary drug to treat your condition, including a statement that all covered formulary drugs on any tier will be or have been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects. This request must be approved by Fallon Health before we will pay for the drug. 

Exclusions: 
Medications listed under “Related Exclusions” in your Evidence of Coverage are considered excluded and are not covered. 

If you are covered under a small group or nongroup plan, and your provider feels that the medications on our formulary are not appropriate for your condition, there is an exception request process available. Your prescriber must support the request by providing a statement that provides justification for the need for the excluded drug to treat your condition. This statement should include a statement that all covered formulary drugs on any tier will be or have been ineffective, would not be as effective as the excluded drug, or would have adverse effects. This request must be approved by Fallon Health before we will pay for the drug. Please contact our pharmacy benefit manager, CVS Caremark, at 1-855-582-2022 to submit an exception request. 

You or your prescribing physician may make an expedited exception request if exigent circumstances exist. Exigent circumstances exist when you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or when you are undergoing a current course of treatment using a non-formulary drug. 

You will be notified within 72 hours of receipt of information sufficient to begin our review for a standard request, or 24 hours of receipt of information sufficient to begin our review for an expedited request. If you disagree with the decision on your standard or expedited exception request above, you may file an external exception request. 

To file a standard or expedited external exception request please contact Fallon Health at 1-800-333-2535 or email us at grievance@fallonhealth.org. We will forward your external exception request to an independent review organization for a review and determination. The same standards and time frames outlined above will apply to standard and expedited external review requests.