Prescription drug Q & A

What is a formulary?

A formulary is a listing of prescription drugs that are approved for coverage by Fallon Health. 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 Health covers both brand-name and generic drugs. All of the drugs in our formularies are available with an extended day supply except specialty drugs and certain narcotics which are prohibited under Massachusetts State Law from being dispensed in quantities greater than a 30-day supply.

Fallon will generally cover the drugs listed in our formularies 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 the formularies change?

Yes, Fallon may add or remove drugs from our formularies during the year. If we remove drugs from or add restrictions to drugs on our formularies 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.

Once in a while, a drug is suddenly recalled because it's been found to be unsafe or for other reasons. If this happens, the plan will immediately remove the drug from the formulary. We will let you know of this change right away. Your provider will also know about this change and can work with you to find another drug for your condition.

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How can I get extra help with paying for my Medicare prescription drug plan costs?

NaviCare members qualify for extra help with Medicare prescription drug plan costs. The extra help is for people with limited income to help to pay for their prescription drug costs. Medicare pays a percentage of drug costs, including monthly prescription drug premiums, annual deductibles, and coinsurance, meaning that your premium and your drug costs are lower. Additionally, those with this extra help are not subject to the coverage gap or a late enrollment penalty.  Find out more about extra help.

Many people are eligible for these savings and don’t even know it. If you know someone who isn't currently receiving any extra help, they can see if they qualify by calling:

  • 1-800-MEDICARE (1-800-633-4227) (24 hours a day/seven days a week).
    TTY users call 1-877-486-2048.
  • Massachusetts Medicaid office:
    1-800-841-2900 (TTY: 1-800-497-4648)
  • Social Security Administration: 1-800-772-1213
    (TTY: 1-800-325-0778), 7 a.m. to 7 p.m., Monday through Friday.

You can also call the numbers above to check on your extra help status or level.

Massachusetts has a State Pharmaceutical Assistance Program called Prescription Advantage. This program may also provide assistance in helping you pay for your prescription drug costs. To find out if you qualify for Prescription Advantage, call 1-800-AGE-INFO (1-800-243-4636), TTY: 1-877-610-0241.

For information about the Centers for Medicare & Medicaid Services (CMS) Best Available Evidence (BAE) policy, visit the CMS website. (This link takes you away from the NaviCare website.)

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What are brand-name drugs?

Brand-name drugs are prescription drugs marketed with a specific name by the company that manufactures it, usually the company which developed and patented it. When patents run out, generic versions of brand-name drugs can be marketed at lower cost by other companies. Our formulary covers both brand-name drugs and generic drugs.

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What are generic drugs?

Generic drugs have the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs. Our formulary covers both brand-name drugs and generic drugs. 

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What is a therapeutic class?

A therapeutic class is the group that a specific drug belongs to based on what the drug is used for. Examples of therapeutic classes are antibiotics, antidepressants or diuretics.

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What is a status/tier?

This is the classification that applies to each drug. Tier 1: Generic; Tier 2: Non-Prefered Generic and Preferred Brand; Tier 3: Non-preferred Brand.

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Are there any restrictions on prescription drug coverage?

Some covered drugs may have requirements or limits on coverage. These requirements and limits may include:

  • Prior Authorization - Part B versus Part D (PA B vs. D): This prescription drug has a Part B versus Part D administrative prior authorization requirement. This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
  • Limited Access (LA): This prescription may be available only at certain pharmacies. For more information, call us at 1-877-700-6996 (TRS 711), 8 a.m.–8 p.m., Monday–Friday. (Oct. 1–Feb. 14, seven days a week.)
  • Prior Authorization (PA): Fallon requires your physician 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, Fallon may not cover the drug.
  • Quantity limit (QL): For certain drugs, Fallon limits the amount of the drug that we will cover. For example, only 12 tablets of fluoxetine delayed-release per each 84-day period.
  • Step Therapy (ST): 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, Fallon  may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Fallon will then cover Drug B. Drugs with step therapy requirements:
  • Mail Order Drug (MO): This prescription drug is available through our mail-order service.
  • Non-Extended Day Supply (NEDS): This prescription cannot be filled for more than a 30-day supply.

You can find out if your drug has any requirements or limits by looking in the “Notes & restrictions” column of the drug search results. You may ask Fallon to make an exception to these restrictions or limits. Click here for information on how to request an exception to the formulary.

All of the drugs in our formularies are available with an extended-day supply except specialty drugs and certain narcotics, which are prohibited under Massachusetts State Law from being dispensed in quantities greater than a 30-day supply.

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What if my drug is not on your formulary?

If you are conducting a search and the drug you are searching for is not found, you should first contact Enrollee Services and ask if that drug is covered.

If you learn that the plan you are on or are interested in does not cover your drug, you have two options:

  • You may ask NaviCare Enrollee Services to mail you a list of similar drugs that are covered by Fallon. When you receive the list, ask your provider to review it and to prescribe a similar drug that is covered by Fallon.
  • You may ask Fallon to make an exception to cover your drug. Click here for information on how to request an exception to the formulary.

Each plan that offers Medicare prescription drug coverage has a transition policy for people taking a drug that is not on our formulary. Read our complete transition policy.

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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 formularies, or may be taking a drug that is on our formularies, 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 they take, we may cover the drugs in certain cases. Read our complete transition policy.

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How do I request an exception to a 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 a 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 limits 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 a greater amount.

Generally, Fallon will only approve your request for an exception if the alternative drugs included on the plan’s formulary 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 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.

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How do I fill prescriptions outside the network?

We have network pharmacies outside of the service area where you can get your drugs covered as a member of NaviCare. Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available. Below are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy. Before you fill your prescription in these situations, call Enrollee Services to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for the reasons listed below, you will have to pay the full cost when you fill your prescription. You may ask us to reimburse you by submitting a Request for Payment of Medical Services form (SCO_2016_82 Approved 03112016, pdf). You should submit this form to us if you fill a prescription at an out-of-network pharmacy, as any amount you pay for a covered Part D drug will help you qualify for catastrophic coverage. If we do pay for the drugs you get at an out-of-network pharmacy, you may still pay more for your drugs than what you would have paid if you had gone to an in-network pharmacy.

  • If you are unable to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service.
  • If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail-order pharmacy (these drugs include orphan drugs or other specialty medications).

Any in-network drug management programs, such as our formulary list, prior authorization and quantity limits, apply to out-of-network purchases.

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How do I fill or refill 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 at the address below.

Our mail-order pharmacy offers four ways to order prescription refills:

  • You can order refills online at www.caremark.com. (This link takes you away from the NaviCare website.)
  • By calling toll-free at 1-800-311-0572 (TRS 711), you can access an automated refill system.
  • By mail: You can mail your prescription to:
    CVS Caremark
    PO Box 2110
    Pittsburgh, PA 15230-2110
  • Physicians can fax in new or refill orders to 1-800-378-0323.

If you use the online service, be sure to sign up for the mail-order pharmacy’s refill reminder program at www.caremark.com. (This link takes you away from the NaviCare website.) With this service, you’ll get convenient email 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?

Usually a mail-order pharmacy order will get to you in no more than 10 days. If the mail-order pharmacy expects a delay of more than 10 days, we will call you and help you decide whether to wait for the medication, cancel the mail order, or fill the prescription at a local pharmacy. If you need to request a rush order due to mail-order delay, you may contact 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), to discuss options that may include filling at a local retail pharmacy or expediting the shipment method. Provide the representative with your ID number and prescription number(s). If you want second day or next day delivery of your medications, you may request this from the customer care representative for an additional charge.

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How do I obtain a prescription if a mail-order is delayed?

Usually a mail-order pharmacy order will get to you in no more than 10 days. If the mail-order pharmacy expects a delay of more than 10 days, we will call you and help you decide whether to wait for the medication, cancel the mail order, or fill the prescription at a local pharmacy. If you need to request a rush order due to mail-order delay, you may contact 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), to discuss options that may include filling at a local retail pharmacy or expediting the shipment method. Provide the representative with your ID number and prescription number(s). If you want second day or next day delivery of your medications, you may request this from the customer care representative for an additional charge.

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What is Medication Therapy Management?

Medication Therapy Management is a free service that is designed to help eligible members stay healthy while taking multiple prescription drugs. Learn more about our Medication Therapy Management Program.

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Are there forms I can use to initiate a Part D appeal or a coverage determination request?

There are two forms you can use:

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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.

H9001_N_2018_10 Approved 10192017
The information on this page was last updated on 10/1/2017.

Medicare Part D online forms