Drug transition policy
As a new member within the first 90 days of membership you may be taking drugs that are not on our formulary or you may be taking a drug that is on our formulary but your ability to get it is limited. Or, you may be a member who is continuing as our member but the list of drugs that we cover has changed at the beginning of the year. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor or other prescriber to decide if you should switch to an appropriate drug that we cover or request a formulary exception (prior authorization approval to continue with the current medication). While you talk to your doctor or other prescriber to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan or for a member that is continuing as our member from one calendar year to the next and a drug you are taking will no longer be on our formulary.
In these situations, for each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply (unless your prescription was written for fewer days), we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception (prior authorization approval to continue with the current medication).
If you are a current member being admitted or discharged from a long-term care facility, you will be able to get an early refill on your medications if needed.
If you are a new member who has been on a medication that is not on our formulary or needs a prior authorization, Fallon Community Health Plan ensures that you will be able to receive a 30-day supply (unless you have a prescription written for fewer days) of this medication within the first 90 days of your membership, as of your effective date of coverage. However, this 30-day supply (unless you have a prescription written for fewer days) will be considered a “transitional supply” of the medication. You will need to either have your provider prescribe a medication that is on our formulary or request a formulary exception (prior authorization approval to continue with the current medication).
When you pick up your prescription, the pharmacist may tell you that the prescription is a transitional supply. Within three business days, you will receive a notice from Fallon Community Health Plan confirming that you received a transitional supply. You also will receive information about how to work with your prescribing provider and Fallon Community Health Plan to identify alternative medications that are on our formulary, an explanation of your right to request a formulary exception (that is, prior authorization approval to continue with the current medication), and the procedures for requesting a formulary exception.
If the pharmacist fills your transitional supply of medication for less than the prescribed amount (due to a plan limitation such as a quantity limit), Fallon Community Health Plan will allow refills of this medication up to the prescribed amount while you are pursuing a formulary exception (prior authorization approval to continue with the current medication).
Except in emergent and urgent care situations, you must use network pharmacies to access the prescription drug benefit. Quantity limits and restrictions may apply.
H9001_N_2012_15 CMS Approved 11072011
The information on this page was last updated on 10/1/2011.