Covered medications


The formulary below lists prescription drugs that are covered by NaviCare HMO SNP and NaviCare SCO. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary and the prescription is filled at a network pharmacy. Some covered prescription drugs have additional requirements and limits: prior authorization, step therapy, limited access (only available at certain pharmacies) and quantity limits. The printed formulary was last updated on March 22, 2017. It is subject to change at any time. For more information on the most recent list of drugs, see our online Part D drug formulary, or contact NaviCare Enrollee Services at 1-877-700-6996 (TRS 711), 8 a.m.–8 p.m., Monday–Friday. (Oct. 1–Feb. 14, seven days a week.)

Changes to the list of covered medications

You may view the PDF documents below to see if there are changes to the 2017 NaviCare list of covered medications. If there are no documents listed below, then there are currently no changes to the list of covered medications.

Formulary Addendum (pdf, SCO_2017_26 Approved 09222016, last updated March 10, 2017)

Prior authorization and step therapy

Prior authorization

Fallon Health requires your provider to get prior authorization for certain drugs. This means that you will need to get approval from Fallon before you fill your prescriptions. If you don’t get approval, NaviCare may not cover the drug. If a drug requires a prior authorization, you'll see a "PA" next to the drug in the online drug formulary search. You can click on the "PA" symbol to see the prior authorization criteria for that medication.

Step therapy

In some cases, Fallon 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, NaviCare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, NaviCare will then cover Drug B.

Drugs with step therapy requirements:

My drug isn't on the covered medications list. What can I do?

Drug transition policy 
Within your first 90 days as a NaviCare member, you may be taking drugs that are not on our formulary, or you may be taking a drug that is on our formulary but your ability to get it is limited. Or, you may be a member who is continuing as our member, but the list of drugs that we cover has changed at the beginning of the year. Or, you may be taking a drug that is on our formulary, but your ability to get it has changed. This policy explains how we can help you transition your drugs.

Request for Medicare prescription drug coverage determination form (SCO_2017_52 Approved 09222016, pdf)
Use this form for you to request an exception or coverage determination for drugs covered by Medicare Part D. You can also access an online version of the coverage determination form. You can also contact CVS Caremark at 1-866-239-4707 (TRS 711) to ask for a coverage decision.

Request for prescription coverage decision SCO-only (SCO_2015_171 Approved 04222015, pdf)
The provider who prescribes your drugs may use this form to request a coverage decision for drugs not covered by Medicare Part D.

Request for redetermination of Medicare prescription drug denial (SCO_2017_50 Approved 09222016, pdf)
Use this form to request a redetermination of a decision if coverage for a prescription was denied.

Request an exception to the formulary

You can ask Fallon 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.
  • Waive coverage restrictions or limits on your drug. For example, for certain drugs, we may limit the amount of the drug we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

Generally, Fallon will only approve your request for an exception if:

  • The alternative drug is not included on the plan’s formulary.
  • Another drug 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 for an initial coverage decision for a formulary or utilization restriction exception. When you are requesting a formulary 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.

Request for Medicare prescription drug coverage determination form (SCO_2017_52 Approved 09222016, pdf)
You or your provider can use this form to request an exception or coverage determination. You can also access an online version of this form.

Other important information about medications

Medication Therapy Management Program
The Medication Therapy Management (MTM) Program is a free service that we offer through NaviCare, if you qualify. You may be invited to participate in a program designed for your specific health and medication needs. You may decide not to participate, but it is recommended that you take full advantage of this covered service if you are selected. Learn more about the Medication Therapy Management Program »

 

Fallon Health is an HMO plan with a Medicare contract and a contract with the Massachusetts Medicaid program. Enrollment in Fallon Health depends on contract renewal. NaviCare is a voluntary program in association with MassHealth/EOHHS and CMS. NaviCare SCO is available to anyone age 65 and older who has MassHealth Standard and lives in the service area. Individuals who also have Medicare Parts A and B may enroll in NaviCare HMO SNP. This information is not a complete description of benefits. Contact the plan for more information. Limitations and restrictions may apply. Benefits may change on January 1 of each year. The Formulary may change at any time. You will receive notice when necessary. To view the PDF files above, you may need to download a free copy of Adobe® Acrobat Reader software on your computer. (This link takes you away from the NaviCare website.)  Adobe® is a registered trademark of Adobe Systems Incorporated.

H9001_N_2017_16 Approved 10142016
The information on this page was last updated on 10/1/2016.

Medicare Part D online forms