Pharmacy prior authorizations

Prior authorization process

Fallon Health collaborates with OptumRx (Fallon's Pharmacy Benefit Manager) and Magellan Rx Management to implement our prior authorization process. For all lines of business, OptumRx reviews pharmacy benefit drugs (patient self-administered drugs, including oral medications and Commercial/Medicaid member diabetic testing supplies). For Medicare members only, Fallon Health reviews glucose monitor and test strip requests.  Magellan Rx Management reviews medical benefit drugs (physician-administered drugs, including home infusion).  

Learn more about our Medical Rx programFAQs | Webinar recording.

How to locate criteria and PA forms

Please use the Online Formulary to determine which medications require Utilization Management (UM).  Each drug with UM includes a link to the criteria, ePA, and fax form.

Example:
Prior authorization example

Important Information regarding the Massachusetts Standard PA Form and Commercial plan members
Please review the criteria posted on the Online Formulary prior to completing the PA form or submitting an ePA and provide all relevant data for each part of the criteria. If there is no specific field for the data on the PA form, please use the "Additional information pertinent to this request" field. For Commercial member PA requests, you must use the state-mandated standard PA form, or otherwise use ePA or telephone. 

Patient-administered drugs (pharmacy benefit)

Our process offers you two ways to submit a prior authorization request for patient self-administered drugs:

  • Electronic prior authorization tool (ePA)
  • Call or fax

Electronic prior authorization tool (ePA)

Fallon and OptumRx have made submitting PAs easy, quick, and convenient.  ePA is a secure and easy method for submitting, managing, tracking PAs, step therapy and non-formulary exception requests. It enables a faster turnaround time of coverage determinations for most PA types and reasons.

Using ePA, you can:

  • Request clinical questions through your integrated EHR or the ePA website.
  • Answer patient-specific clinical questions electronically and submit for review.

For more information about OptumRx prior authorizations:

Call or fax

To serve you quickly and efficiently, we have separate phone and fax numbers for our Medicare, Medicaid and commercial plans. To determine which phone or fax number to use, find the member's plan name on their ID card and locate it in the chart below.

When faxing, please use the form in the drug link on the Online Drug Formulary

Line of business

Phone

Fax

Mail

Commercial plans

  • Direct Care
  • Select Care
  • Steward Community Care
  • Community Care
  • Fallon Preferred Care
  • City of Worcester Advantage

1-844-720-0035

1-844-403-1029

Optum Prior
Authorization Department  
P.O. Box 25183
Santa Ana, CA 92799

Medicaid ACO/MassHealth

  • Fallon 365 Care
  • Berkshire Fallon Health
    Collaborative
  • Wellforce Care Plan

1-844-720-0033

1-844-403-1029

Optum Prior
Authorization Department  
P.O. Box 25183
Santa Ana, CA 92799

Medicare

  • Fallon Medicare Plus
  • NaviCare

1-844-657-0494

1-844-403-1028

Optum Prior
Authorization Department  
P.O. Box 25183
Santa Ana, CA 92799

PACE

  • Summit ElderCare
    Fallon Health Weinberg-PACE

1-844-722-1701

1-844-403-1028

Optum Prior
Authorization Department  
P.O. Box 25183
Santa Ana, CA 92799

Physician-administered drugs (medical benefit)

Our process offers you two ways to submit a prior authorization request for physician-administered drugs:

  • Electronic prior authorization web portal
  • Call or fax

Electronic prior authorization web portal

Fallon and Magellan Rx Management have made submitting PAs easy, quick, and convenient through the ih.magellanrx.com website.

  • Please click “Providers and Physicians” to get to the login page, or
  • “New Access Request-Provider” to request access.

Call or fax

  • Call: 1-800-424-1740
  • Fax: 1-888-656-6671

Learn more about our Medical Rx programFAQs | Webinar recording.

Medicare glucose monitors and test strips

For Medicare members only, Fallon Health reviews Medicare glucose monitor and test strip requests. Please fax requests to 1-508-791-5101 or call 508-368-9825, option 5, option 2.

CVS Caremark is a registered trademark of CVS Pharmacy, Inc. Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members’ private health information.