Covered medications

The formulary below lists prescription drugs that are covered by NaviCare SCO and NaviCare HMO SNP. We 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 such as prior authorization, step therapy, limited access (only available at certain pharmacies) and quantity limits. The formulary 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 call NaviCare Enrollee Services at 1-877-700-6996 (TRS 711), 8 a.m.–8 p.m., Monday–Friday (Oct. 1–March 31, seven days a week). If you would like a formulary and over-the-counter drug list mailed to you, please complete our online form.

2024

• Search our online Part D formulary to see if your medication is covered
  
  
• Download the list of covered prescription medications (H8928_240002_C Formulary ID: 00024364 Version: 13; Last updated: 03/27/24)
  This document is a comprehensive listing of the drugs approved by Medicare for NaviCare Part D prescription coverage.
  Lista de medicamentos cubiertos (H8928_240002SP_C Formulario ID: 00024364 Versión: 13; Actualizado el: 03/27/24)
  Este documento indica cuáles son los medicamentos con receta que cubre NaviCare.
  
  
• Download the list of covered over-the-counter (OTC) medications and certain Medicare-excluded indications/medications - MassHealth coverage (H8928_240353_C, pdf) 
  This document includes the OTC drugs covered with a prescription and certain Medicare-excluded indications/drugs covered with prescription and prior authorization as part of your MassHealth Standard coverage.

Changes to the list of covered medications 

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

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

Drug transition policy 
Within your first 108 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 (H8928_220030_C, pdf)
Use this form 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 OptumRx at 1-844-657-0494 (TRS 711) to ask for a coverage decision.

Request for prescription drug coverage determination (SCO-only) (SCO_220031_C, 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 (H8928_220048_C, 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 Health 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 ("formulary exception").
• Waive coverage restrictions or limits on your drug ("utilization restriction exception"). 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 Health will only approve your request for an exception if the alternative drugs included on the plan’s formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects (side 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 (H8928_220030_C, 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 no-cost service that we offer through NaviCare for those who qualify. This program is designed to help members learn more about their medications and how they affect their health and well-being. It is recommended that you take full advantage of this covered service if you are selected. Learn more about the Medication Therapy Management Program.

Part B step therapy

In some cases, Fallon Health 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, your plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, your plan will then cover Drug B. Step Therapy may be required for the medications listed in the table below.

NaviCare is a voluntary program in association with MassHealth/EOHHS and CMS. 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.

H8928_240094_C
The information on this page was last updated on 10/1/2023.