Drug transition policy
Fallon provides a transition policy that allows you to obtain a temporary fill on most medications.
As a new member, you may be taking a drug that is not on our list of covered drugs. Or, the drug is on our list, but is limited in some way.
As an existing member, the drug list may have changed from last year so your drug may no longer be on our list or is now limited in some way.
Ask your doctor or prescriber if you should switch to a drug on our list, or if you should ask us to cover your current drug. This is called requesting a coverage determination or exception.
In some cases, we will cover a temporary supply of your drug. This is called a transition fill. This will give you and your doctor enough time to look for drugs on our list while you keep taking your drug. To help you transition to a new drug smoothly, our pharmacist may be able to help you and your doctor find a covered drug that works for you.
If you are not in a nursing home
For new members, we may cover a 30-day supply of your drug during the first 90 days after you enroll.
For existing members, we may cover a 30-day supply of your drug during the first 90 days after the start of the plan year.
This supply is temporary. After your first 30-day supply, we will not pay for these drugs. You will need to have your provider prescribe a drug that is on our list. Or, you may ask us to cover your drug if our drug list is not right for you.
You will need to fill your prescription at a network pharmacy to get your temporary supply.
If you are in a nursing home
We may cover a maximum day supply of 98 days. You can get refills in the first 90 days after you enroll. We cover more than one refill of these drugs for the first 90 days if you are a new member.
You can get an early refill if you are entering a long-term care facility. You can also do this if you are leaving a facility.
If you are past the first 90 days, but need a drug not on our list, we will cover a 31-day emergency supply.
When you pick up your prescription
Your pharmacy may tell you it is a transition supply. You will get a letter from Fallon Health within three business days of you picking up your prescription. The letter will give you information about how to find other drugs on our list. You will also be told about your right to ask Fallon to cover your drug if our drug list is not right for you. You may also hear from Fallon or your doctor about what other drug you can take that is on our list of covered drugs.
Copayment amounts for transition supplies are based on approved cost-sharing tiers and are consistent with cost-sharing amounts that Fallon charges for drugs approved under a coverage exception. If you receive extra help for your Medicare prescription drug coverage, the copayments for transition supplies of medication will not exceed the current statutory maximum copayment amounts
Fallon Health is an HMO/HMO-POS plan with a Medicare contract. Enrollment in Fallon Health depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, and/or copayments/coinsurance may change on January 1 of each year. The Formulary and/or pharmacy network may change at any time. You will receive notice when necessary.
H9001_F_2017_21 Approved 10172016
The information on this page was last updated on 10/1/2016.
Call us toll-free at 1-888-340-5504 (TRS 711), 8 a.m.–8 p.m., Monday–Friday. (Oct. 1–Feb. 14, seven days a week.)