FCHP MassHealth formulary and pharmacy FAQ

 

What is a drug name?

A drug name is the name of the drug.

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What is a drug type?

FCHP MassHealth covers brand-name drugs, generic drugs, and some over-the-counter drugs. The drug type column shows which of these categories the drug is in. A generic drug has the same active ingredient as the brand name drug. Generic drugs usually cost less than brand name drugs and are approved by the Food and Drug Administration (FDA).

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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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What is a copayment type?

This is the classification that applies to each drug. The Tier 1 copayment type includes all generic and over-the-counter drugs that are within the antihyperglycemics, antihypertensives, and antihyperlipidemics drug classes. The copayment for Tier 1 drugs is $1.

The Tier 2 copayment type includes all generic and over-the-counter drugs that are within drug classes other than those identified as Tier 1. The copayment for Tier 2 drugs is $2.

The Tier 3 copayment type includes all drugs classified as brand name drugs. The copayment for Tier 3 drugs is $3.

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Are there any other restrictions on prescription drug coverage ?

Some covered drugs may have additional requirements or limits on coverage. You can find out if your drug has any requirements or limits by looking in the "Requirements/limits" columns of the drug search results. 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.
  • Limited Access (LA): This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call FCHP Customer Service at 1-800-341-4848 (TTY users, please call TRS Relay 711), Monday through Friday, 8 a.m. to 6 p.m.

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What are my pharmacy copayments?

As a member of FCHP MassHealth, most of the benefits and services you receive are at no out-of-pocket cost to you.  However, there are some copayments associated with your pharmacy benefit.  You would be responsible for paying:

  • $3 for brand-name prescription drugs (Tier 3 copayment type)
  • $2 for generic prescription and over-the-counter drugs (generic and brand-name) for which you have a prescription from the doctor (Tier 2 copayment type)
  • $1 for generic prescription and over-the-counter drugs (generic and brand-name) used to treat diabetes, hypertension and hyperlipidemia (Tier 1 copayment type).  These drugs are called antihyperglycemics (such as metformin), antihypertensives (such as propranolol), and antihyperlipidemics (such as simvastatin).
  • This applies to both first-time prescriptions and refills

You must pay the copayment if you can afford it, but if you can't, do not go without the medicine. If you are unable to pay the copayment, your pharmacist must still give you the medicine you need. However, if you have not paid a copayment, you still owe the money to your pharmacist and you will need to pay it back later.

Exceptions to your pharmacy copayments
You will not have to pay a copayment for any pharmacy service covered by your health plan if:

  • You are under age 19.
  • You are enrolled in MassHealth because you were in the care and custody of the Department of Children and Families (DCF), formerly the Department of Social Services (DSS) when you turned 18, and your MassHealth coverage was continued; or
  • You are pregnant, or you get pharmacy services during the 60 days following the month your pregnancy ends. (You must tell the pharmacist you're pregnant.)
  • You are an inpatient in an acute hospital, nursing facility, chronic-disease or rehabilitation hospital, or intermediate-care facility for the mentally disabled.
  • You are getting hospice care.
  • You are receiving family planning supplies.
  • You have reached your annual copayment cap as described below.

Your pharmacist will not always know if these exceptions apply to you. Be sure to tell your pharmacist if they do.

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What is the annual pharmacy copayment cap?

There is a maximum $200 "cap" (limit) on the amount of pharmacy copayments each MassHealth member will be required to make in a calendar year, unless you are not required to pay a copayment as listed above. (A calendar year is January through December.) The cap is the total dollar amount of the copayments you have been charged, whether or not you have actually paid them.

Each member of your family age 19 or older, unless they are not required to pay a copayment as listed above, will need to pay copayments until he or she reaches the cap. When the cap is reached, you cannot be charged additional copayments during that calendar year.

Once the copayments you have been charged meet the total pharmacy copayment "cap," you will not have to pay any copayments for the rest of the calendar year. For example, if you have met your pharmacy cap by September, you will not have to make pharmacy copayments until January 1 of the next year.

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What if I have Medicare Part D coverage?

If you are a Fallon Community Health Plan member with Medicare coverage, your prescription drug benefit may be covered by a Medicare Prescription Drug Coverage (Part D) plan. Most of your prescription drugs will be covered under your Medicare Part D benefit. You should have a separate ID card for your Medicare Prescription Drug Coverage. You will need to show your Medicare Part D ID card when filling a prescription. There are some drugs that FCHP will continue to cover. For example, FCHP will continue to cover your over-the-counter (OTC) drugs. Fallon Community Health Plan copayment exceptions will still apply for FCHP covered drugs.

To find out more about your Medicare Prescription Drug Coverage, you may:

  • Contact Medicare at 1-800-633-4227 (TTY: 1-877-486-2048);
  • Go to Medicare's Web site at www.medicare.gov;
  • Refer to your Medicare and You Handbook;
  • Go to the Centers for Medicare & Medicaid Services Web site at www.cms.com.

Remember to carry all your ID cards with you when you go to the pharmacy. When you file a prescription, please show your Fallon Community Health Plan Member ID card and your Medicare Prescription ID card.

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What types of pharmacy programs do you have?

FCHP uses a number of pharmacy programs to promote the safe and appropriate use of prescription drugs. Not all drugs are in a pharmacy program. Drugs which belong to a program have clinical guidelines that must be met before we cover them.

If your provider feels that it is medically necessary for you to take a drug that's in one of our programs, he or she can submit a prior authorization request to FCHP. This request will be reviewed by a clinician. If the drug is medically necessary, FCHP will cover the drug. If the prior authorization request is denied, you and your authorized appeal representative can appeal the decision. See the "How to file complaints, compliments, inquiries, grievances and appeals" section of your Member Handbook for more information.

Prior Authorization Program
Some drugs always require prior authorization. If your provider feels that it is medically necessary and meets any applicable criteria for use, he or she can submit a prior authorization request that will be reviewed by a clinician. If the drug is medically necessary, FCHP will cover the drug. If the prior authorization request is denied, you and your authorized appeal representative can appeal the decision. See the "How to file complaints, compliments, inquiries, grievances and appeals" section of your Member Handbook for more information.

Step Therapy Program
Some types of drugs have many options. This program requires that a member tries certain first-level drugs first before FCHP will cover another drug of that type. If you and your provider feel that a certain first-level drug is not appropriate to treat a medical condition, your provider can submit a prior authorization request that will be reviewed by a clinician. If the drug is medically necessary, FCHP will cover the drug. If the prior authorization request is denied, you and your authorized appeal representative can appeal the decision. See the "How to file complaints, compliments, inquiries, grievances and appeals" section of your Member Handbook for more information.

New-to-Market Medication Program
FCHP reviews new drugs for safety and efficacy before we add them to our formulary. If your provider feels that a new-to-market medication is medically necessary, he or she can submit a prior authorization request that will be reviewed by a clinician. If approved, FCHP will cover the drug. If the prior authorization request is denied, you and your authorized appeal representative can appeal the decision. See the "How to file complaints, compliments, inquiries, grievances and appeals" section of your Member Handbook for more information.

Quantity Limitation Program
Ensures the safe and appropriate use of some medications by covering a specific amount that can be dispensed at one time. If your provider feels that a quantity greater than the specified amount is medically necessary, he or she can submit a prior authorization request that will be reviewed by a clinician. If approved, FCHP will cover the drug. If the prior authorization request is denied, you and your authorized appeal representative can appeal the decision. See the "How to file complaints, compliments, inquiries, grievances and appeals" section of your Member Handbook for more information.

Specialty Pharmacy Program
Requires that some drugs be supplied by a specialty pharmacy. These drugs include injectable and intravenous drugs that are often used to treat chronic conditions like Hepatitis C or multiple sclerosis. These types of diseases require additional expertise and support. Specialty pharmacies have knowledge in these areas and can provide additional support to members and providers. 

Mandatory Generic Substitution Program
Massachusetts law requires a member to try an "AB rated" generic drug before its brand counterpart is covered. The Food and Drug Administration has determined that certain generic drugs are therapeutically equivalent "AB rated") to their brand counterparts. This means that the "AB rated" generic drug is as effective as its brand name drug. Massachusetts law also requires the dispensing of the "AB rated" generic drug, unless your provider indicates the brand is medically necessary by writing on the prescription "no substitutions." The Food and Drug Administration (FDA) determines that certain generic drugs are therapeutically equivalent ("AB rated") to their brand name alternatives. This means that the "AB rated" generic drug is as effective as the brand name drug. If your provider determines that the brand name drug is medically necessary, he or she may request prior authorization that will be reviewed by a clinician. If approved, FCHP will cover the drug. If the prior authorization request is denied, you and your authorized appeal representative can appeal the decision. See the "How to file complaints, compliments, inquiries, grievances and appeals" section of your Member Handbook for more information.

Generally, you cannot obtain a refill until most or all of the previous supply has been used. In most cases, FCHP will only allow you to get a 30-day supply of medicine at a time. Occasionally, for safety reasons or as directed by your health care prescriber, FCHP will allow less than a 30-day supply. FCHP makes these decisions by following the U.S. Food and Drug Administration (FDA) guidelines.

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Are there any exclusions in the prescription drug benefit?

FCHP's prescription drug benefit features an open Preferred Drug List, in which the following drugs or services are excluded. However, if you or your provider feels that it is medically necessary for you to take a listed drug, he or she can submit a prior authorization that will be reviewed by a clinician and, if approved, FCHP will cover the drug. If the prior authorization request is denied, you and your authorized appeal representative can appeal the decision. See the how to file complaints, compliments, inquiries, grievances and appeals section for more information.

  • Fertility medications
  • Experimental treatment including medications that are experimental or that have not been approved for general sale and distribution by the U.S. Food and Drug Administration
  • Over-the-counter medications that are not included on the MassHealth list of covered drugs
  • Drugs prescribed for purposes that are not medically necessary, for example, cosmetic purposes, to enhance athletic performance, for appetite suppression or for non-covered services/conditions
  • Non-emergency prescriptions filled at a pharmacy that is not in FCHP's network
  • Drugs used for erectile dysfunction

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