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 formulary are available with an extended day supply except Tier 5 drugs, Tier 6 drugs, specialty drugs, opioid drugs, and certain narcotics which are prohibited under Massachusetts State Law from being dispensed in quantities greater than a 30-day supply. These drugs are noted on the formulary as "Non-Extended Day Supply (NEDS)."
Fallon Health will generally cover the drugs listed in our formulary 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 formulary change?
Yes, Fallon Health may add or remove drugs from our formulary during the year. If we remove drugs from or add restrictions to drugs on our formulary during the year, we must notify you of the change at least 30 days before the date that the change becomes effective. Click here to view notices of formulary changes.
At any time, we may immediately remove a brand-name drug, a reference product, or a brand-name biological product from our formulary if we're replacing it with a corresponding drug (generic of a brand-name drug, an interchangeable biological product of a reference product, or an unbranded biological for a brand-name biological product) that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions.
We may not tell you in advance before we make that change—even if you're currently taking the brand-name drug, reference product, or brand name biological product.
You or your prescriber can ask us to make an exception and continue to cover the brand-name drug for you.
If you're taking the brand-name drug, a reference product, or a brand-name biological product at the time we make the change, we'll provide you with information about the specific change(s) we made and the specific drugs involved. This will also include information on the steps you may take to request a coverage determination or an exception to cover the drug. You may not get this notice before we make the change.
Once in a while, a drug is suddenly recalled because it's been found to be unsafe or for other reasons. If this happens, Fallon Health will immediately remove the drug from the formulary. We'll let you know of this change as soon as possible. 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?
People with limited incomes may qualify for Medicare's Extra Help to pay for their prescription drug costs. If you're eligible, Medicare could help pay a percentage of your drug costs, including monthly prescription drug premiums, annual deductibles and coinsurance. Additionally, those who qualify won't be subject to a late enrollment penalty. Find out more about Extra Help.
If you qualify for Extra Help with your Medicare prescription drug plan costs, your premium and your drug costs could be lower. When you join Fallon Medicare Plus, Medicare will tell us how much Extra Help you're getting. Then, we'll let you know the amount you'll pay.
If you aren’t currently receiving any Extra Help from Medicare, you can see if you qualify by calling:
- 1-800-MEDICARE (1-800-633-4227) (24 hours a day/7 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), 8 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 link takes you away from the Fallon Medicare Plus website).
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 Fallon Medicare Plus 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 them, usually the company which developed and patented them. 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 are biological drugs?
Brand-name drugs that are more complex than typical drugs (for example, drugs that are based on a protein) are called biological drugs. On the drug list, when we refer to “drugs,” this could mean a drug or a biological drug.
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What are biosimilar drugs?
Since biological drugs are more complex than typical drugs, instead of having a generic form, they have alternatives that are called biosimilars. Generally, generics and biosimilars work just as well as the brand-name drug or biological drug and usually cost less. There are generic drug substitutes or biosimilar alternatives available for many brand-name drugs and some biological 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 antibacterials, antidepressants, or cardiovascular agents.
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What is a status/tier?
This is a classification that relates to the cost-sharing (copay or coinsurance) that you pay for the drug. For example, in the formulary for Fallon Medicare Plus, Tier 1: Preferred generic; Tier 2: Generic; Tier 3: Preferred brand; Tier 4: Non-preferred drug; Tier 5: Specialty drugs (certain drugs whose costs are more than $950 for up to a 30-day supply); Tier 6: Select care drugs (certain vaccines and anti-opioid drugs). Tier 1 drugs tend to have lower cost-sharing than other tiers. Tier 5 drugs tend to have higher cost-sharing than other tiers.
Important Message About What You Pay for Vaccines
Our plan covers most Part D vaccines at no cost to you, even if you haven't paid your deductible (if you have one). For more information, call us at 1-800-325-5669 (TRS 711), 8 a.m.–8 p.m., Monday–Friday (7 days a week, October 1–March 31).
Important Message About What You Pay for Insulin.
You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven't paid your deductible (if you have one).
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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 (B/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.
- Home Infusion (HI): This prescription drug is covered under our medical benefit. For more information, call us at 1-800-325-5669 (TRS 711), 8 a.m.–8 p.m., Monday–Friday (7 days a week, October. 1–March 31).
- Limited Access (LA): This prescription may be available only at certain pharmacies. For more information, call us at 1-800-325-5669 (TRS 711), 8 a.m.–8 p.m., Monday–Friday (7 days a week, October. 1–March 31).
- Mail-Order Drug (MO): This prescription drug is available through our mail-order pharmacy.
- Non-Extended Day Supply (NEDS): This prescription cannot be filled for more than a 30-day supply.
- Prior Authorization (PA): Fallon Medicare Plus requires your physician to get prior authorization for certain drugs. This means that you'll need to get approval from Fallon Health before you fill your prescriptions. If you don’t get approval, Fallon Health may not cover the drug.
- Prior Authorization for New Starts only (PA NS): Fallon Medicare Plus requires a prior authorization for certain drugs for new prescriptions only. This means that if you're newly starting on this drug, you need to get approval from Fallon Medicare Plus before you fill your prescriptions. If you don’t get approval, Fallon Medicare Plus may not cover the drug. Prior authorization isn't required if you've been previously filling this drug with Fallon Medicare Plus.
- Quantity Limit (QL): For certain drugs, Fallon Medicare Plus limits the amount of the drug that we'll cover. For example, only 4 capsules per each 28-day period.
- Step Therapy (ST): In some cases, Fallon Health requires you to first try certain drugs to treat your medical condition before we'll 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 doesn't work for you, your plan will then cover Drug B.
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 Health 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 formulary are available with an extended-day supply except Tier 5 drugs, Tier 6 drugs, specialty drugs, opioid drugs and certain narcotics, which are prohibited under Massachusetts State Law from being dispensed in quantities greater than a 30-day supply. These drugs are noted on the formulary as "Non-Extended Day Supply (NEDS)."
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Is it safe to take my prescription opioid medication?
Prescription opioid pain medications—like oxycodone (OxyContin®), hydrocodone (Vicodin®), morphine, and codeine—can help treat pain after surgery or after an injury, but they also carry serious risks, like addiction, overdose, and death.
As a health plan, we've put steps in place—such as reviews at the pharmacy and drug management programs—to make sure you can get what you need safely.
If you have any safety concerns about any prescriptions you're taking, please call your provider.
For more information, please read our opioid FAQ.
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What if my drug is not on the formulary?
If you're conducting a search and the drug you are searching for isn't found, you should first contact Customer Service and ask if that drug is covered.
If you learn that the plan you're on, or are interested in, doesn't cover your drug, you have two options:
- You may ask your provider to prescribe a similar drug that is covered by Fallon Health. You may ask Customer Service to mail you a list of similar drugs that are covered by Fallon Health. When you receive the list, ask your provider to review it and to prescribe a similar drug that is covered by Fallon Health.
- You may ask Fallon Health 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 isn't 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 aren't on our formulary, or may be taking a drug that is on our formulary, but their ability to get it is limited. We may cover the drug in certain cases while the member talks to their doctor to decide if they should switch to an appropriate drug that we cover or to request a formulary exception so that we'll cover the drug they take. Read our complete transition policy.
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How do I 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 a drug even if it is not on our formulary ("formulary exception"). If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
- You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier ("tiering exception"). If approved this would lower the amount you must pay for your drug. Members aren't allowed to request a tiering exception for Tier 5 drugs.
- You can ask us to waive coverage restrictions or limits on your drug ("utilization restriction exception"). For example, for certain drugs, Fallon Medicare Plus limits the amount of the drug that we'll cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, Fallon Health will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions wouldn't 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, tiering, step therapy, or utilization restriction exception. When you're requesting a formulary, tiering, step therapy, 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 believes 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 (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 Fallon Medicare Plus. Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy isn't 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 Customer Service 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'll have to pay the full cost (rather than paying just copayment/coinsurance) when you fill your prescription. You may ask us to reimburse you for our share of the cost by submitting a Medicare Part D claim form (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're 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're 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.
- Ask your doctor to fax or electronically send a new prescription to OptumRx. This is just like when your provider calls it into your regular pharmacy. As long as your provider is contracted with the plan, they'll have all of the information they need to do this.
- Call OptumRx at 1-844-657-0494 (TRS 711) and they'll ask you for your medication and prescriber information, and other information they may need to process your prescription.
- Go online to optumrx.com. (This link takes you away from the Fallon Medicare Plus website.) Register (if you haven’t already) and once you log in, go to "My prescriptions."
- By mail. You can mail your prescription and mail-order form to:
OptumRx
PO Box 2975
Mission, KS 66201
Make sure your doctor writes your mail-order prescription for a 90-day supply for drugs in Tiers 2, 3, or 4 or a 100-day supply for Tier 1 drugs.
Our mail-order pharmacy offers a few ways to order prescription refills. We suggest that you request a refill within 7-10 business days from the day you are going to run out of your medication. There are 3 different ways you can order refills through mail order:
- Online. Visit optumrx.com. (This link takes you away from the Fallon Medicare Plus website.) From there you can enter your information to request a refill.
- By phone. Call 1-844-657-0494 (TRS 711). You'll need your prescription information, found on your medication bottle
- By mail. With each mail-order prescription you'll receive a refill slip with a pre-addressed return envelope that you can mail in.
Learn more about mail order prescriptions.
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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 10-15 days. If the mail-order pharmacy expects a delay of more than 10 days, we'll call you and help you decide whether to wait for the medication, cancel the mail order, or fill the prescription at a local pharmacy. Learn more about mail-order prescriptions.
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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 10-15 days. If the mail-order pharmacy expects a delay of more than 10 days, we'll 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 Customer Service at 1-800-325-5669 (TRS 711) 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. Learn more about mail-order prescriptions.
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What is Medication Therapy Management?
Medication Therapy Management is a free service designed to help members learn more about their medications and how they affect their health and well-being. 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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When you join the Medicare Prescription Payment Plan, you no longer pay the pharmacy for your prescription drugs. Instead, Fallon Health works directly with your pharmacy to spread out the costs of all of your prescriptions over the remainder of the calendar year.
Each month, we'll send you a bill showing the amount you owe, when it's due, and how you can make a payment. There's no additional cost and no increase to your prescription copayments. Learn more and enroll.
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