• Provider Tools
• Criteria, policies and guidelines
• Forms
• Pharmacy
• • Online drug formulary
  • Pharmacy prior authorization
  • Specialty drug list
  • New-to-market medication evaluation
  • Opioid management program and pain management alternatives
  • Prescribing with OptumRx
• Training and resources
• Provider Manual
• News and announcements
• Frequently asked questions
• Contact us

Pharmacy prior authorizations

Prior authorization process - all plans

Fallon Health collaborates with OptumRx (Fallon's Pharmacy Benefit Manager) and Prime Therapeutics Management LLC to implement our prior authorization process. For all lines of business, OptumRx reviews pharmacy benefit drugs (patient self-administered drugs, including oral medications and Commercial/Medicaid member diabetic testing supplies). For Medicare members only, Fallon Health reviews glucose monitor and test strip requests. Prime Therapeutics Management reviews medical benefit drugs (physician-administered drugs, including home infusion).  

How to locate criteria and PA forms - commercial, Medicare, NaviCare, and PACE plans

Please use the Online Formulary to determine which medications require Utilization Management (UM).  Each drug with UM includes a link to the criteria, ePA, and fax form.

Example:

Important Information regarding the Massachusetts Standard PA Form and Commercial plan members
Please review the criteria posted on the Online Formulary prior to completing the PA form or submitting an ePA and provide all relevant data for each part of the criteria. If there is no specific field for the data on the PA form, please use the "Additional information pertinent to this request" field. For Commercial member PA requests, you must use the state-mandated standard PA form, or otherwise use ePA or telephone. 

How to locate criteria and PA forms – Medicaid/MassHealth ACO plans

Please visit MassHealth’s website directly for online formulary listing, prior authorization criteria, and forms.    
Prior authorizations MUST be submitted as indicated below.

Patient-administered drugs (pharmacy benefit) - all plans

Our process offers you two ways to submit a prior authorization request for patient self-administered drugs:

• Electronic prior authorization tool (ePA)
• Call or fax

Electronic prior authorization tool (ePA)

Fallon and OptumRx have made submitting PAs easy, quick, and convenient.  ePA is a secure and easy method for submitting, managing, tracking PAs, step therapy and non-formulary exception requests. It enables a faster turnaround time of coverage determinations for most PA types and reasons.

Using ePA, you can:

• Request clinical questions through your integrated EHR or the ePA website.
• Answer patient-specific clinical questions electronically and submit for review.

For more information about OptumRx prior authorizations:

• Submitting a PA request
• PA guidelines and procedures
• PA forms

Call or fax

To serve you quickly and efficiently, we have separate phone and fax numbers for our Medicare, Medicaid and commercial plans. To determine which phone or fax number to use, find the member's plan name on their ID card and locate it in the chart below.

When faxing, please use the form in the drug link on the Online Drug Formulary or, for Medicaid/MassHealth ACO plans, use the form on the MassHealth website. 

Physician-administered drugs (medical benefit) - all plans

Our process offers you two ways to submit a prior authorization request for physician-administered drugs:

• Electronic prior authorization web portal
• Call or fax

Electronic prior authorization web portal

Fallon and Prime Therapeutics have made submitting PAs easy, quick, and convenient through the Prime Therapeutics provider portal, gatewaypa.com. Please click "New Provider Access Request" under the "Sign In" box to request access. 

• Call: 1-800-424-1740
• Fax: 1-888-656-6671

Medicare glucose monitors and related testing supplies (including test strips) - Medicare, NaviCare, and PACE plans

For Medicare members only, Fallon Health reviews Medicare glucose monitor and related testing supply (including test strips) requests. Please fax requests to 1-508-791-5101 or call 508-368-9825, option 5, option 2.

• Prior Authorization form for Medicare Diabetic Glucose Meters and Test Strips (pdf)

Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members’ private health information.