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 will generally cover the drugs listed in our formulary 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 this formulary change?
Yes, Fallon Community Health Plan may add or remove drugs from our formulary during the year. If we remove drugs from our formulary 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, Tier 1: Preferred generic drugs; Tier 2: Non-preferred generic and preferred-brand drugs; and Tier 3: Non-preferred brand-name drugs. Tier 1 drugs tend to have lower copayments than Tier 3 drugs.
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What is a copayment type?
This is the type of copayment that you will pay for drugs. For example, for Fallon Senior Plan Value 1 members, “Generic’” means you will pay $1.10 or $2.40 for generic drugs; “Brand” means you will pay $3.20 or $6.00 for brand-name drugs; “1” means you will pay $5 for a 30-day supply of Tier-1 drugs; “2” means you will pay $20 for a 30-day supply of Tier-2 drugs; and “3” means you will pay $40 for a 30-day supply of Tier-3 drugs.
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What are quantity limits?
For certain drugs, Fallon Community Health Plan limits the amount of the drug per month that FCHP will cover.
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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:
- Prior authorization (PA): Fallon Community Health Plan requires that you obtain prior authorization for certain drugs. This means that you will need to obtain approval from FCHP before you fill your prescriptions. If you do not obtain approval, FCHP may not cover the drug.
- Quantity limits (QL): For certain drugs, Fallon Community Health Plan limits the amount of the drug per month that FCHP will cover.
- Non-Part D covered drugs (ND): A prescription drug labeled "ND" is not normally covered under Medicare Part D prescription drug coverage. The amount you pay when you fill a prescription for this drug does 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 extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.
- Limited Access (LA): This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service at 1-800-868-5200, seven days a week from 8 a.m. to 8 p.m. TDD/TTY users should call 1-877-608-7677.
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 extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
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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 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 formulary, or may be taking a drug that is on our formulary, 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
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How do I request an exception to the formulary?
You can ask Fallon Senior Plan 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 your drug even if it is not on our formulary.
- 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 in our highest tier that is subject to the tiering exceptions process, you can ask us to cover it at the cost-sharing amount that applies to drugs in the lowest tier that is subject to the tiering exceptions process 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 formulary, 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 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
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?
Your prescriptions will be delivered free to your home within 10 to 14 days from when our mail-order pharmacy receives your prescription or refill request. If you have any questions about your prescription order, or don’t receive your prescription within 14 days, call our mail-order pharmacy toll-free at 1-800-311-0572 (TDD/TTY: 1-866-236-1069), 24 hours a day, seven days a week. You may also call FCHP’s Customer Service at 1-800-868-5200 (TDD/TTY: 1-877-608-7677), seven days a week from 8 a.m. to 8 p.m., Eastern time.
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How do I obtain a prescription if a mail-order is delayed?
If you don’t receive your prescription within 14 days, call our mail-order pharmacy toll-free at 1-800-311-0572 (TDD/TTY: 1-866-236-1069), 24 hours a day, seven days a week. You may also call FCHP’s Customer Service at 1-800-868-5200 (TDD/TTY: 1-877-608-7677), seven days a week from 8 a.m. to 8 p.m., Eastern time. We will work to help you obtain your needed prescription.
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How can I get extra help with paying for my Medicare prescription drug plan costs?
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) (TDD/TTY: 1-877-486-2048)
24 hours a day/seven days a week
- The Massachusetts Medicaid office at 1-800-841-2900 (TDD/TTY: 1-800-497-4648)
- The Social Security Administration at 1-800-772-1213 (TDD/TTY 1-800-325-0778) between 7 a.m. and 7 p.m., Monday through Friday.
For information about the Centers for Medicare & Medicaid Services (CMS) Best Available Evidence (BAE) policy, visit the CMS Web site.
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 the plan’s formulary. Read our complete transition policy.
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Call us toll-free at 1-888-340-5504 (TDD/TTY: 1-877-608-7677), 8 a.m. to 8 p.m., seven days a week.