Drug transition policy
Fallon Health 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. You will need to fill your prescription at a network pharmacy to get your temporary supply. In most cases, your transition supply will process automatically at the pharmacy.
Transition fill
If you are not in a long-term care facility (LTC)
We may cover a 30-day supply of your drug during the first 108 days after you enroll or after the start of the plan year.
If your prescription is dispensed in a quantity less than a 30-day supply, we will allow refills up to a total of a 30-day supply.
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 the drugs on our list are not right for your condition.
On a case-by-case basis, we may allow a transition extension if your coverage determination/exception or appeal request is being processed and you are outside of the normal transition period.
If you are in a long-term care facility (LTC)
We may cover a 31-day supply of your drug during the first 108 days after you enroll or after the start of the plan year.
If your prescription is dispensed in a quantity less than a 31-day supply, we will allow refills up to a total of a 31-day supply.
This supply is temporary. After your first 31-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 the drugs on our list are not right for your condition.
If you are past the first 108 days, but need a drug not on our list, we will cover a 31-day emergency supply.
You can get early refills if you are entering or leaving a long-term care facility.
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 filling 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 your condition. You may also hear from Fallon or your doctor about what other drugs you can take that are 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 determination or 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.