Covered medications - online drug formulary

Choose whether you have a Medicare individual plan or a group plan. Choose “individual” if you have enrolled in Fallon Senior Plan HMO directly through Fallon Community Health Plan or if you are a prospect. Choose “group” if you receive your benefits through your or your spouse’s current or former employer.

Download printable versions of the formularies

Individual

Group

Please note: This represents our Medicare formularies. These printable formularies were last updated on August 1, 2011. They are subject to change at any time.


Prior authorization and step therapy

Prior authorization

Fallon Community Health Plan (FCHP) requires your physician to get prior authorization for certain drugs. This means that you will need to get approval from FCHP before you fill your prescriptions. If you don’t get approval, Fallon Senior Plan may not cover the drug. If a drug requires a prior authorization, you'll see a "PA" next to the drug in the online drug formulary search. You can click on the "PA" symbol to see the prior authorization criteria for that medication.

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, Fallon Senior Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Fallon Senior Plan will then cover Drug B.

Drugs with step therapy requirements:


Formulary changes

You may view the PDF documents below to see if there are changes to the Fallon Senior Plan formularies. If there are no documents listed below, then there are currently no changes to the list of covered medications.

To view the PDF files above, you may need to download a free copy of Adobe® Acrobat Reader software on your computer.

Drug name Date of notice Effective date Reason for change
ERIVEDGE 150MG CAPS 4/20/2012 5/1/2012 Add
INLYTA 1MG TABS 4/20/2012 5/1/2012 Add
INLYTA 5MG TABS 4/20/2012 5/1/2012 Add
levetiracetam er 500mg tb24 4/20/2012 5/1/2012 Add
levetiracetam er 750mg tb24 4/20/2012 5/1/2012 Add
olanzapine 10mg solr 4/20/2012 5/1/2012 Add
PICATO 0.015% GEL 4/20/2012 5/1/2012 Add
PICATO 0.05% GEL 4/20/2012 5/1/2012 Add
VIREAD 40MG/GM POWD 4/20/2012 5/1/2012 Add
VIREAD 150MG TABS 4/20/2012 5/1/2012 Add
VIREAD 200MG TABS 4/20/2012 5/1/2012 Add
VIREAD 250MG TABS 4/20/2012 5/1/2012 Add
brimonidine tartrate 0.15% soln 3/1/2012 3/1/2012 Add
CAPRELSA 100MG TABS 3/1/2012 3/1/2012 Add
CAPRELSA 300MG TABS 3/1/2012 3/1/2012 Add
cromolyn sodium 100mg/5ml conc 3/1/2012 3/1/2012 Add
lamivudine/zidovudine 150mg; 300mg tabs 3/1/2012 3/1/2012 Add
methylphenidate hcl er 20mg cp24 3/1/2012 3/1/2012 Add
methylphenidate hcl er 30mg cp24 3/1/2012 3/1/2012 Add
methylphenidate hcl er 40mg cp24  3/1/2012 3/1/2012 Add
PEGASYS PROCLICK 135MCG/0.5ML SOLN 3/1/2012 3/1/2012 Add
PROMACTA 12.5MG TABS 3/1/2012 3/1/2012 Add
SYLATRON 296MCG KIT 3/1/2012 3/1/2012 Add
SYLATRON 444MCG KIT 3/1/2012 3/1/2012 Add
SYLATRON 888MCG KIT 3/1/2012 3/1/2012 Add
vestura 3mg; 0.02mg tabs 3/1/2012 3/1/2012 Add
alfuzosin hcl er 10mg tb24 2/1/2012 2/1/2012 Add
amethia 0; 0 tabs 2/1/2012 2/1/2012 Add
amethyst 20mcg; 90mcg tabs 2/1/2012 2/1/2012 Add
ANDRODERM 2MG/24HR PT24 2/1/2012 2/1/2012 Add
ANDRODERM 4MG/24HR PT24  2/1/2012 2/1/2012 Add
atorvastatin calcium 10mg tabs  2/1/2012 2/1/2012 Add
atorvastatin calcium 20mg tabs  2/1/2012 2/1/2012 Add
atorvastatin calcium 40mg tabs  2/1/2012 2/1/2012 Add
atorvastatin calcium 80mg tabs  2/1/2012 2/1/2012 Add
atovaquone/proguanil hcl 250mg; 100mg tabs  2/1/2012 2/1/2012 Add
briellyn 35mcg; 0.4mg tabs  2/1/2012 2/1/2012 Add
budesonide 3mg cp24  2/1/2012 2/1/2012 Add
carbamazepine er 100mg cp12  2/1/2012 2/1/2012 Add
carbamazepine er 200mg cp12  2/1/2012 2/1/2012 Add
carbamazepine er 300mg cp12  2/1/2012 2/1/2012 Add
COMPLERA 200MG; 25MG; 300MG TABS  2/1/2012 2/1/2012 Add
disulfiram 250mg tabs  2/1/2012 2/1/2012 Add
disulfiram 500mg tabs  2/1/2012 2/1/2012 Add
emoquette 0.15mg; 30mcg tabs  2/1/2012 2/1/2012 Add
felbamate 400mg tabs  2/1/2012 2/1/2012 Add
felbamate 600mg tabs  2/1/2012 2/1/2012 Add
felbamate 600mg/5ml susp  2/1/2012 2/1/2012 Add
flucytosine 250mg caps  2/1/2012 2/1/2012 Add
flucytosine 500mg caps  2/1/2012 2/1/2012 Add
fluocinolone acetonide 0.01% oil  2/1/2012 2/1/2012 Add
fluocinolone acetonide body 0.01% oil  2/1/2012 2/1/2012 Add
FOCALIN XR 25MG CP24  2/1/2012 2/1/2012 Add
FOCALIN XR 35MG CP24  2/1/2012 2/1/2012 Add
fondaparinux sodium 10mg/0.8ml soln  2/1/2012 2/1/2012 Add
fondaparinux sodium 2.5mg/0.5ml soln  2/1/2012 2/1/2012 Add
fondaparinux sodium 5mg/0.4ml soln  2/1/2012 2/1/2012 Add
fondaparinux sodium 7.5mg/0.6ml soln  2/1/2012 2/1/2012 Add
imipenem/cilastatin 250mg; 250mg solr  2/1/2012 2/1/2012 Add
imipenem/cilastatin 500mg; 500mg solr  2/1/2012 2/1/2012 Add
introvale 0.03mg; 0.15mg tabs  2/1/2012 2/1/2012 Add
JAKAFI 10MG TABS  2/1/2012 2/1/2012 Add
JAKAFI 15MG TABS  2/1/2012 2/1/2012 Add
JAKAFI 20MG TABS  2/1/2012 2/1/2012 Add
JAKAFI 25MG TABS  2/1/2012 2/1/2012 Add
JAKAFI 5MG TABS  2/1/2012 2/1/2012 Add
lamivudine 150mg tabs  2/1/2012 2/1/2012 Add
lamivudine 300mg tabs 2/1/2012 2/1/2012 Add
levofloxacin 250mg tabs 2/1/2012 2/1/2012 Add
levofloxacin 25mg/ml soln 2/1/2012 2/1/2012 Add
levofloxacin 500mg tabs 2/1/2012 2/1/2012 Add
levofloxacin 750mg tabs 2/1/2012 2/1/2012 Add
methylergonovine maleate 0.2mg tabs 2/1/2012 2/1/2012 Add
naproxen 500mg tabs 2/1/2012 2/1/2012 Add
NULOJIX 250MG SOLR 2/1/2012 2/1/2012 Add
olanzapine 10mg tabs 2/1/2012 2/1/2012 Add
olanzapine 15mg tabs 2/1/2012 2/1/2012 Add
olanzapine 2.5mg tabs 2/1/2012 2/1/2012 Add
olanzapine 20mg tabs 2/1/2012 2/1/2012 Add
olanzapine 5mg tabs 2/1/2012 2/1/2012 Add
olanzapine 7.5mg tabs 2/1/2012 2/1/2012 Add
olanzapine odt 10mg tbdp 2/1/2012 2/1/2012 Add
olanzapine odt 15mg tbdp 2/1/2012 2/1/2012 Add
olanzapine odt 20mg tbdp 2/1/2012 2/1/2012 Add
olanzapine odt 5mg tbdp 2/1/2012 2/1/2012 Add
orsythia 20mcg; 0.1mg tabs 2/1/2012 2/1/2012 Add
TASIGNA 150MG CAPS 2/1/2012 2/1/2012 Add
tranexamic acid 100mg/ml soln 2/1/2012 2/1/2012 Add
XALKORI 200MG CAPS 2/1/2012 2/1/2012 Add
XALKORI 250MG CAPS 2/1/2012 2/1/2012 Add
YERVOY 50MG/10ML SOLN 2/1/2012 2/1/2012 Add
ZELBORAF 240MG TABS 2/1/2012 2/1/2012 Add
ZENPEP 136000UNIT; 25000UNIT; 85000UNIT CPEP 2/1/2012 2/1/2012 Add
ZENPEP 16000UNIT; 3000UNIT; 10000UNIT CPEP 2/1/2012 2/1/2012 Add

H9001_2012_720_18_r3 CMS Approved 01042012

The information on this page was last updated on 12/13/2011.

Call us toll-free at 1-888-340-5504 (TTY users, please call TRS Relay 711), Monday through Friday, 8 a.m. to 8 p.m. (From October 15 through February 14, we're available seven days a week.)

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