Prescription medication coverage*
- If you have a "Y" after the "Rx" label, you have FCHP prescription coverage. An "N" means that you don't.
- The numbers after "COPAY" are your copayments. The 1st number is your copayment for Tier 1 drugs, the 2nd is for Tier 2, and the 3rd is for Tier 3.
The plan covers medically necessary prescription drugs that are in our formulary, according to the requirements and guidelines discussed below. You may pay copayments for the services below; you also may be responsible for a deductible for certain services.
Who can write your prescription
A plan provider or a provider you've seen through an authorized referral can write your prescription.
Filling your prescription
You can fill your prescription at a plan pharmacy or through our mail-order program. (There are some medications that can't be mailed and aren't available through the mail-order program.)
Prescription drugs are generally dispensed for up to a 30-day supply. A one-month copayment will be charged for up to a 30-day supply. In some instances, the plan has established dispensing limitations, which may include a quantity limit on certain medications. For maintenance medication, you may obtain up to a 90-day supply. We follow FDA, state and federal dispensing guidelines. You generally cannot obtain a refill until most or all of the previous supply has been used. Please note: Your doctor may prescribe medication in a dose that isn't available through the purchase of a single prescription. In these cases, you may need to fill more than one prescription—and pay a copayment for each—to achieve the desired dose.
Generic and brand-name drugs
A generic drug is a drug product that meets the approval of the U.S. Food and Drug Administration and is equivalent to a brand-name product in terms of quality and performance. It may differ in certain other characteristics (e.g., shape, flavor, or preservatives). By law, generic drug products must contain identical amounts of the same active drug ingredient as the brandnameproduct.
You will generally receive a generic drug from plan pharmacies anytime one is available, unless your doctor has directed the pharmacist to only dispense a specific brand-name drug. However, some brand-name drugs don't have a generic equivalent. In both these cases, you'll receive the brand-name drug and will be responsible for the appropriate tiered copayment for that drug.
What's covered?
Covered items (some of these medications and covered items may require prior authorization)
Prescription medication**
Contraceptive drugs and devices
Hormone replacement therapy
Injectable agents (self-administered***)
Syringes (including insulin syringes) or needles when medically necessary
Supplies for the treatment of diabetes, including:
- Blood glucose monitoring strips
- Urine glucose strips
- Lancets
- Ketone strips
Certain injectable medications administered in the home setting, when approved by FCHP and received through a plan-approved pharmacy vendor<
What isn't covered?
Noncovered items
Drugs that you can buy without a prescription, including prescription medications that are available as over-the-counter products
Drugs that are investigational or that have not been approved for general sale and distribution by the U.S. Food and Drug Administration
Drugs that are not used in accordance with FDA approved labeling, including, but not limited to: unapproved doses, unapproved duration of therapy and unapproved indications
Drugs that require prior authorization, if prior authorization is not received
Drugs prescribed for purposes that are not medically necessary. This includes, but is not limited to, drugs for cosmetic purposes, to enhance athletic performance, for appetite suppression, or for other noncovered conditions. This also includes drugs that do not meet medical criteria.
Prescriptions obtained within the FCHP service area at a non-plan pharmacy
Nonemergency prescriptions filled outside the plan service area
Vitamins and minerals, whether or not a prescription is required, are excluded from coverage, unless listed in the FCHP formulary
Over-the-counter birth control preparations or devices
Drugs that are prescribed for anything other than the U.S. Food and Drug Administration’s approved usage. (This does not include the off-label uses of covered prescription drugs used in the treatment of HIV/AIDS or cancer when used in accordance with state law. This also does not include bone marrow transplants for breast cancer as required by state law.)
Products used for any dental condition that is not covered under your FCHP dental benefit
Medications used for preference or convenience
Replacement of more than one lost/mishandled medication per prescription per calendar year
Prescription drugs that are a combination of a covered prescription item and an item that is specifically excluded, such as vitamins, minerals, medical foods or formulas
Medications that are new to the market that have not been reviewed by FCHP for safety and adverse events. These medications are not covered by FCHP until they have been reviewed and guidelines for their use have been developed. This could take up to 180 days post-marketing.
For details on your specific benefits, coverage, and copayments:
-
Refer to your Member Handbook or Benefit Summary
or
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Call our customer service department at:
1-800-868-5200 (TDD/TTY: 877-608-7677), Monday through Friday, 8 a.m. to 6 p.m.
* Benefits and coverage may vary by product, plan design and employer. For specific details regarding your FCHP plan, benefits and features, please check with your employer or contact a member of our customer service team at 1-800-868-5200 (TDD/TTY: 1-877-608-7677), Monday through Friday, 8 a.m. to 6 p.m. Eastern time. MassHealth members can call the MassHealth Customer Service Center at: 1-800-841-2900 (TDD/TTY: 1-800-497-4648) Monday through Friday, 8 a.m. to 5 p.m.
** Coverage of certain drugs is based on medical necessity. For these drugs, you will need prior authorization from the plan. Your doctor should request authorization from the plan before he or she writes the prescription and give us the clinical information that we need to make our decision. We will review the authorization request according to our criteria for medical necessity.
*** Injectables administered in the doctor’s office or under other professional supervision are generally covered as a medical benefit.