Prescription drug Q & A
What is a formulary?
A formulary is a listing of prescription drugs that are approved for coverage by Fallon Health. 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 Health covers both brand-name and generic drugs. All of the drugs in our formularies are available with an extended day supply except specialty drugs, opioid drugs and certain narcotics which are prohibited under Massachusetts State Law from being dispensed in quantities greater than a 30-day supply. These drugs are noted on the formulary as "Non-Extended Day Supply (NEDS)."
Fallon Health 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 formulary change?
Yes, Fallon Health may add or remove drugs from our formulary during the year. If we remove drugs from, or add restrictions to, drugs on our formulary during the year, we must notify you of the change at least 30 days before the date that the change becomes effective. Click here to view notices of formulary changes.
We may immediately remove a brand-name drug on our formulary if we are replacing it with a new generic drug that will appear with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand-name drug on our formulary, but immediately add new restrictions.
We may not tell you in advance before we make that change—even if you are currently taking the brand-name drug.
You or your prescriber can ask us to make an exception and continue to cover the brand-name drug for you.
If you are taking the brand-name drug at the time we make the change, we will provide you with information about the specific change(s) we made. This will also include information on the steps you may take to request an exception to cover the brand-name drug. You may not get this notice before we make the change.
Once in a while, a drug is suddenly recalled because it's been found to be unsafe or for other reasons. If this happens, the plan will immediately remove the drug from the formulary. We will let you know of this change right away. Your provider will also know about this change and can work with you to find another drug for your condition.
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How can I get extra help with paying for my Medicare prescription drug plan costs?
NaviCare members qualify for Medicare's Extra Help with Medicare prescription drug plan costs. Extra Help is for people with limited income to help to pay for their prescription drug costs. Medicare pays a percentage of drug costs, including monthly prescription drug premiums, annual deductibles, and coinsurance, meaning that your premium and your drug costs are lower. Additionally, those with this Extra Help are not subject to the coverage gap or a late enrollment penalty. Find out more about Extra Help.
Many people are eligible for these savings and don’t even know it. If you know someone who isn't currently receiving any Extra Help, they can see if they qualify by calling:
- 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048 (applications), 24 hours a day, 7 days a week;
- The Social Security Office at 1-800-772-1213, between 8 am to 7 pm, Monday through Friday. TTY users should call 1-800-325-0778; or
- Massachusetts’ MassHealth (Medicaid) Office (applications) 1-800-841-2900 Monday–Friday, 8 a.m.–5 p.m.
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 website. (This link takes you away from the NaviCare website.)
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What are brand-name drugs?
Brand-name drugs are prescription drugs marketed with a specific name by the company that manufactures it, usually the company which developed and patented it. When patents run out, generic versions of brand-name drugs can be marketed at lower cost by other companies. Our formulary covers both brand-name drugs and generic drugs.
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What are generic drugs?
Generic drugs have the same active-ingredient formula as the equivalent brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs. Our formulary covers both brand-name drugs and generic drugs.
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What are biological drugs?
Brand name drugs that are more complex than typical drugs (for example, drugs that are based on a protein) are called biological drugs. On the drug list, when we refer to “drugs,” this could mean a drug or a biological drug.
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What are biosimilar drugs?
Since biological drugs are more complex than typical drugs, instead of having a generic form, they have alternatives that are called biosimilars. Generally, generics and biosimilars work just as well as the brand name drug or biological drug and usually cost less. There are generic drug substitutes or biosimilar alternatives available for many brand name drugs and some biological drugs.
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What is a therapeutic class?
A therapeutic class is the group that a specific drug belongs to based on what the drug is used for. Examples of therapeutic classes are antibacterials and cardiovascular agents.
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Are there any restrictions on prescription drug coverage?
Some covered drugs may have requirements or limits on coverage. These requirements and limits may include:
- Prior Authorization - Part B versus Part D (B/D): 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.
- Home Infusion (HI): This prescription drug is covered under our medical benefit. For more information, call us at 1-877-700-6996 (TRS 711), 8 a.m.–8 p.m., Monday–Friday. (Oct. 1–March 31, seven days a week.)
- Limited Access (LA): This prescription may be available only at certain pharmacies. For more information, call us at 1-877-700-6996 (TRS 711), 8 a.m.–8 p.m., Monday–Friday. (Oct. 1–March 31, seven days a week.)
- Mail-Order Drug (MO): This prescription drug is available through our mail-order service.
- Non-Extended Day Supply (NEDS): This prescription cannot be filled for more than a 30-day supply.
- Prior Authorization (PA): Fallon Health requires your physician to get prior authorization for certain drugs. This means that you will need to get approval from Fallon Health before you fill your prescriptions. If you don’t get approval, Fallon Health may not cover the drug.
- Prior Authorization for New Starts only (PA NS): Fallon Health requires a prior authorization for certain drugs for new prescriptions only. This means that if you are newly starting on this drug, you need to get approval from Fallon Health before you fill your prescriptions. If you don’t get approval, Fallon Health may not cover the drug. Prior authorization is not required if you have been previously filling this drug with Fallon Health.
- Quantity limit (QL): For certain drugs, Fallon Health limits the amount of the drug that we will cover. For example, only 4 capsules per each 28-day period.
- Step Therapy (ST): In some cases, Fallon Health 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, your plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, your plan will then cover Drug B.
You can find out if your drug has any requirements or limits by looking in the “Notes & Restrictions” column of the drug search results. You may ask Fallon Health to make an exception to these restrictions or limits. Click here for information on how to request an exception to the formulary.
All of the drugs in our formularies are available with an extended-day supply except specialty drugs, opioid drugs and certain narcotics, which are prohibited under Massachusetts State Law from being dispensed in quantities greater than a 30-day supply. These drugs are noted on the formulary as "Non-Extended Day Supply (NEDS)."
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Is it safe to take my prescription opioid medication?
Prescription opioid pain medications—like oxycodone (OxyContin®), hydrocodone (Vicodin®), morphine, and codeine—can help treat pain after surgery or after an injury, but they carry serious risks, like addiction, overdose, and death.
As a health plan, we have put steps in place—such as reviews at the pharmacy and drug management programs—to make sure you can get what you need safely.
If you have any safety concerns about any prescriptions you are taking, please call your provider.
For more information, please read our opioid FAQ.
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What if my drug is not on the formulary?
If you are conducting a search and the drug you are searching for is not found, you should first contact Enrollee Services and ask if that drug is covered.
If you learn that the plan you are on or are interested in does not cover your drug, you have two options:
- You may ask your provider to prescribe a similar drug that is covered by NaviCare. You may ask NaviCare Enrollee Services to mail you a list of similar drugs that are covered by Fallon Health. When you receive the list, ask your provider to review it and to prescribe a similar drug that is covered by Fallon Health.
- You may ask Fallon Health to make an exception to cover your drug. Click here for information on how to request an exception to the formulary.
Each plan that offers Medicare prescription drug coverage has a transition policy for people taking a drug that is not on our formulary. Read our complete transition policy.
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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 formulary, or may be taking a drug that is on our formulary, but their ability to get it is limited. We may cover the drugs in certain cases 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 they take. Read our complete transition policy.
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How do I request an exception to a formulary?
You can ask Fallon Health to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
- You can ask us to cover a drug even if it is not on our formulary ("formulary exception").
- You can ask us to waive coverage restrictions or limits on your drug ("utilization restriction exception"). For example, for certain drugs, Fallon Health limits 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 a greater amount.
Generally, Fallon Health will only approve your request for an exception if the alternative drugs included on the plan’s formulary 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, step therapy or utilization restriction exception. When you are requesting a formulary, step therapy 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 NaviCare. 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 Enrollee Services 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 will have to pay the full cost when you fill your prescription.
- 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 medications).
You may ask us to reimburse you by submitting a Medicare Part D claim form. You should submit this form to us if you fill a prescription at an out-of-network pharmacy. 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.
All in-network drug management programs, such as our formulary list, prior authorization and quantity limits, apply to out-of-network purchases.
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How do I fill or refill a prescription through mail order?
There are a few different ways in which you may have prescriptions filled through mail-order.
Ask your doctor to fax or electronically send a new prescription to OptumRx. This is just like when your provider calls it into your regular pharmacy. As long as your provider is contracted with the plan, they will have all of the information they need to do this.
- Call OptumRx at 1-844-657-0494. They will ask you for your medication and prescriber information, and other information they may need to process your prescription.
- Go online to optumrx.com. (This link takes you away from the NaviCare website.) Register (if you haven’t already) and once you log in, go to "My prescriptions."
- By mail. You can mail your prescription and mail-order form to:
OptumRx
PO Box 2975
Mission, KS 66201
Make sure your doctor writes your mail-order prescription for a 100-day supply.
Our mail-order pharmacy offers a few ways to order prescription refills. We suggest that you request a refill within 7-10 business days from the day you are going to run out of your medication. There are three different ways you can order refills through mail order:
- Online. Visit optumrx.com. (This link takes you away from the NaviCare website.) From there you can enter your information to request a refill.
- By phone. Call 1-844-657-0494. You will need your prescription information, found on your medication bottle
- By mail. With each mail-order prescription you will receive a refill slip with a pre-addressed return envelope that you can mail in.
Learn more about mail-order pharmacy.
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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 within 10-15 days. If the mail-order pharmacy expects a delay of more than 10 days, we will call you and help you decide whether to wait for the medication, cancel the mail order, or fill the prescription at a local pharmacy. Learn more about mail-order pharmacy.
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How do I obtain a prescription if a mail order is delayed?
Usually a mail-order pharmacy order will get to you within 10-15 days. If the mail-order pharmacy expects a delay of more than 10 days, we will call you and help you decide whether to wait for the medication, cancel the mail order, or fill the prescription at a local pharmacy. If you need to request a rush order due to mail-order delay, you may contact Enrollee Services at 1-877-700-6996 (TRS 711), 8 a.m.–8 p.m., Monday–Friday (Oct. 1–March 31, seven days a week), to discuss options that may include filling the prescription at a local retail pharmacy or expediting the shipment method. Provide the representative with your NaviCare member ID number and prescription number(s). If you want second-day or next-day delivery of your medications, you may request this for an additional charge. Learn more about mail-order pharmacy.
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What is Medication Therapy Management?
Medication Therapy Management is a free service designed to help members learn more about their medications and how they affect their health and well-being. Learn more about our Medication Therapy Management Program.
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Are there forms I can use to start a Part D appeal or a coverage determination request?
There are two forms you can use:
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NaviCare is a voluntary program in association with MassHealth/EOHHS and CMS.
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The information on this page was last updated on 10/1/2023.