Prescription drug Q & A
What is a formulary?
A formulary is a listing of prescription drugs that are approved for coverage by Fallon Community Health Plan. These drugs are classified by therapeutic category or disease class. They are considered preferred therapy for a given population and are the drugs to be used by our providers in prescribing medications. Fallon Community Health Plan covers both brand-name and generic drugs. All of the drugs in our formulary are available with an extended day supply except certain narcotics which are prohibited under Massachusetts State Law from being dispensed in quantities greater than a 30-day supply.
Fallon Community Health Plan will generally cover the drugs listed in our formularies as long as the drug is medically necessary, the prescription is filled at a network pharmacy and other plan rules are followed.
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Can the formularies change?
Yes, Fallon Community Health Plan may add or remove drugs from our formularies during the year. If we remove drugs from or add restrictions to drugs on our formularies during the year, we must notify you of the change at least 60 days before the date that the change becomes effective. Click here to view notices of formulary changes.
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What are generic drugs?
A generic drug has the same active-ingredient formula as the brand-name drug. Generic drugs usually cost less than brand-name drugs and are approved by the Food and Drug Administration (FDA) to be as safe and as effective as brand-name drugs. Fallon Community Health Plan covers both brand-name drugs and generic drugs.
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What is a drug name?
A drug name is the name of the drug.
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What is a drug class?
A drug class is the group that a specific drug belongs to based on what the drug is used for. Examples of drug classes are antibiotics, antidepressants or diuretics.
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What are tiers?
This is the classification that applies to each drug. For example, in our Fallon Senior Plan Rx formulary, Tier 1: Preferred generic drugs; Tier 2: Preferred brand-name drugs; Tier 3: Non-preferred brand-name drugs; and Tier 4: Specialty drugs (this tier includes certain drugs whose costs are more than $600 for up to a 30-day supply). Tier 1 drugs tend to have lower cost-sharing than other tiers.
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What are quantity limits?
For certain drugs, Fallon Community Health Plan limits the amount of the drug per month that we will cover.
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What is step therapy?
Step therapy is a utilization tool that requires you first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed.
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Are there any other restrictions on prescription drug coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
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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.
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Excluded drug (ED): 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.
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Limited Access (LA): 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.
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Prior authorization (PA): 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.
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Quantity limit (QL): 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.
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Step Therapy (ST): Step therapy is a utilization tool that requires you first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed.
You can find out if your drug has any requirements or limits by looking in the “Requirements/limits” columns of the drug search results. You may ask Fallon Community Health Plan to make an exception to these restrictions or limits. Click here for information on how to request an exception to the formulary.
Our plans cover drugs not normally covered by Medicare Part D (benzodiazepine and barbiturate therapeutic category drugs). And because these drugs are not normally covered by Medicare Part D, the amounts you pay when you fill a prescription for these drugs do not count toward your total drug costs. This means that the amount you pay does not help you qualify for catastrophic coverage. In addition, if you are receiving Medicare's extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
All of the drugs in our formulary are available with an extended-day supply except certain narcotics, which are prohibited under Massachusetts State Law from being dispensed in quantities greater than a 30-day supply.
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What if my drug is not on your formularies?
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:
- 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.
- You may ask FCHP to make an exception to cover your drug. Click here for information on how to request an exception to the formulary.
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What is a transition policy?
A transition policy is for new or continuing members in our plan, who may be taking drugs that are not on our formularies, or may be taking a drug that is on our formularies, but their ability to get it is limited. While the member talks to their doctor to decide if they should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take, we may cover the drugs in certain cases during the first 90 days of membership in our plan. Read our complete transition policy in English or lea nuestra póliza completa de transición de medicamentos en Español.
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What if my drug is not covered on a plan’s formulary?
Each plan that offers Medicare prescription drug coverage has a transition policy for people taking a drug that is not on our formularies. Read our complete transition policy in English or lea nuestra póliza completa de transición de medicamentos en Español.
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How do I request an exception to a formulary?
You can ask Fallon Community Health 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 Tier-4 drugs.)
- You can ask us to cover your drug even if it is not on our formularies.
- 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 formularies, 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.
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How do I fill prescriptions outside the network?
We have network pharmacies outside of the service area where you can get your drugs covered as a member of Fallon Senior Plan. Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available. Below are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy. Before you fill your prescription in these situations, call Customer Service to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for the reasons listed below, you may have to pay the full cost (rather than paying just copayment/coinsurance) when you fill your prescription. You may ask us to reimburse you for our share of the cost by submitting a paper claim. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy, as any amount you pay for a covered Part D drug will help you qualify for catastrophic coverage. If we do pay for the drugs you get at an out-of-network pharmacy, you may still pay more for your drugs than what you would have paid if you had gone to an in-network pharmacy.
- If you are unable to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service.
- If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail-order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals).
Any in-network drug management programs, such as prior authorization and quantity limits, apply to out-of-network purchases.
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How do I fill a prescription through mail-order?
There are a few different ways in which you may have prescriptions filled through mail-order. Your provider can call in your prescription directly to our mail-order pharmacy by calling 1-800-378-5697, option 2, faxing it to
1-800-378-0323, or you can mail in the prescription to our mail-order pharmacy.
Our mail-order pharmacy offers four ways to order prescription refills:
- You can order refills online at www.caremark.com.
- By calling toll-free at 1-800-311-0572 (TDD/TTY: 1-866-236-1069), you can access an automated refill system.
- By mail: You can mail your prescription to:
CVS Caremark Mail Service
PO Box 94467
Palatine, IL 60094-4467
- Physicians can fax in new or refill orders to the fax number above.
If you use the online service, be sure to sign up for the mail-order pharmacy’s refill reminder program at www.caremark.com. With this service, you’ll get convenient e-mail notices from the mail-order pharmacy when it’s time to refill or renew a prescription.
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What is the maximum turnaround time for processing and shipping of all mail orders?
Usually a mail-order pharmacy order will get to you in no more than 14 days. However, sometimes your mail-order may be delayed. Our mail service employs state-of-the-art technology to track and monitor the status of prescription orders throughout the dispensing process. Each step of dispensing requires the identification of all associates involved in handling the order. We generate a daily report which identifies orders that are delayed due to an eligibility issue, medication out of stock, physician call, etc. This report always identifies the oldest order in house, which gains the highest priority for resolution. We will call you to advise you of the reason for the delay and to determine if the medication is urgently needed. If necessary, we will ship the order via overnight delivery.
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How do I obtain a prescription if a mail-order is delayed?
Our mail service employs state-of-the-art technology to track and monitor the status of prescription orders throughout the dispensing process. Each step of dispensing requires the identification of all associates involved in handling the order. We generate a daily report which identifies orders that are delayed due to an eligibility issue, medication out of stock, physician call, etc. This report always identifies the oldest order in house, which gains the highest priority for resolution. We will call you to advise you of the reason for the delay and to determine if the medication is urgently needed. If necessary, we will ship the order via overnight delivery.
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How can I get extra help with paying for my Medicare prescription drug plan costs?
People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for seventy-five percent of drug costs, including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. Find out more about extra help.
If you qualify for extra help with your Medicare prescription drug plan costs, your premium and your drug costs could be lower. When you join Fallon Senior Plan, Medicare will tell us how much extra help you are getting. Then, we will let you know the amount you will pay.
If you aren’t currently receiving any extra help, you can see if you qualify by calling:
- 1-800-MEDICARE (1-800-633-4227).
TTY users call 1-877-486-2048 (24 hours a day/seven days a week)
- Massachusetts Medicaid office:
1-800-841-2900 (TTY: 1-800-497-4648)
- Social Security Administration: 1-800-772-1213
(TTY: 1-800-325-0778), 7 a.m. to 7 p.m., Monday through Friday.
You can also call the numbers above to check on your extra help status or level.
Massachusetts has a State Pharmaceutical Assistance Program called Prescription Advantage. This program may also provide assistance in helping you pay for your prescription drug costs. To find out if you qualify for Prescription Advantage, call 1-800-AGE-INFO (1-800-243-4636), TTY: 1-877-610-0241.
For information about the Centers for Medicare & Medicaid Services (CMS) Best Available Evidence (BAE) policy, visit the CMS Web site.
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H9001_2012_720_18 CMS Approved 10172011
The information on this page was last updated on 10/1/2011.
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.)