Covered medications—online drug formulary

Search for a medication in our online formulary tool

Choose a formulary:

Choose a formulary. Fallon Medicare Plus Orange HMO Fallon Medicare Plus Green HMO Fallon Medicare Plus Blue HMO Fallon Medicare Plus Premier HMO Medical benefit formulary

Download a printable formulary

Fallon Health Formulary (coming soon) 

Or: Request a printed formulary. 

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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, Oct. 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, Oct. 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 Health 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 Health 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 Health before you fill your prescriptions. If you don’t get approval, Fallon Health 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)."

Part B step therapy

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. Step Therapy may be required for the medications listed in the table below. Choose "Medical benefit formulary" from the dropdown above to search for your drug and any restrictions that may apply.