How to use the Fallon Senior Plan online drug formulary

Choosing the plan you are enrolled in or would like to enroll in

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 Saver Rx HMO member, you would select “Fallon Senior Plan Saver Rx HMO” 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 menu 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 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 a list of codes and an explanation of each that may apply.

Legend:

BD	This prescription drug has a Part B versus Part D administrative prior authorization requirement. This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
ED	Excluded Drug. This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.
LA	Limited Access. This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at 1-800-325-5669, Monday through Friday, 8 a.m. to 8 p.m. (TTY users, please call TRS Relay 711.) From October 15 to February 14, we’re available seven days a week.
PA	Prior authorization. Fallon Community Health Plan requires your physician to get prior authorization for certain drugs. This means that you will need to get approval from Fallon Community Health Plan before you fill your prescriptions. If you don’t get approval, Fallon Senior Plan may not cover the drug.
QL	Quantity Limit. For certain drugs, Fallon Community Health Plan limits the amount of the drug that Fallon Senior Plan will cover. For example, only four tablets of PROZAC WEEKLY per 28 days. This may be in addition to a standard one-month or three-month supply.
ST	Step Therapy. Step therapy is a utilization tool that requires you first try another drug to treat your medical condition brefore we will cover the drug your physician may have initially prescribed.

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. Members in Fallon Senior Plan Super Saver Rx HMO and Fallon Senior Plan Saver Rx HMO are not allowed to request an exception for a Tier-4 formulary drug.

• 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 a Tier-3 drug, you can ask us to cover it at the cost-sharing amount that applies to drugs in Tier-2 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.

• Medicare Part D online coverage determination form
  Use this form to initiate a prior authorization request for your medication.
• Medicare Part D online appeal form
  Use this form to initiate an appeal for a denied medication.

H9001_2012_720_18 CMS Approved 10172011

The information on this page was last updated on 10/1/2011