Prescription drug Q & A

What is a formulary?

A formulary is a listing of prescription drugs that are approved for coverage by Fallon Health Weinberg. These drugs are classified by therapeutic category and therapeutic 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 Weinberg covers both brand-name and generic drugs. All of the drugs in our formulary are available with an extended day supply except certain narcotics which are prohibited under New York State Law from being dispensed in quantities greater than a 30-day supply.

Fallon Health Weinberg 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 Weinberg 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 60 days before the date that the change becomes effective. See notices of formulary changes

Once in a while, a drug is suddenly recalled because it's been found to be unsafe or for other reasons. If this happens, the plan will immediately remove the drug from the formulary. We will let you know of this change right away. Your provider will also know about this change and can work with you to find another drug for your condition.

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What are generic drugs?

Our formulary covers both brand name drugs and 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.

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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 antibiotics, antidepressants or diuretics.

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What are quantity limits?

For certain drugs, Fallon Health Weinberg limits the amount of the drug per month that we will cover.

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What is step therapy?

Step therapy is a utilization tool that requires you first try another drug to treat your medical condition before we will cover the drug your provider may have initially prescribed.

Are there any other restrictions on prescription drug coverage?

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

  • Prior Authorization - Part B versus Part D (PA B vs. 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.
  • Limited Access (LA): This prescription may be available only at certain pharmacies. For more information, call Customer Service at 1-855-561-7247 (TTY 711), 8 a.m.–8 p.m., Monday–Friday. (Oct. 1–Feb. 14, seven days a week).
  • Prior Authorization (PA): Fallon Health Weinberg requires your physician to get prior authorization for certain drugs. This means that you will need to get approval from Fallon Health Weinberg before you fill your prescriptions. If you don’t get approval, Fallon Health Weinberg may not cover the drug.
  • Quantity Limit (QL): For certain drugs, Fallon Health Weinberg limits the amount of the drug that we will cover. For example, only four tablets of fluoxetine delayed-release would be covered per each 28 days.
  • Step Therapy (ST): Step therapy is a tool that requires you first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed.
  • Mail Order Drug (MO): This prescription drug is available through our mail-order service.

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 Weinberg 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 certain narcotics, which are prohibited under New York State Law from being dispensed in quantities greater than a 30-day supply.

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What if my drug is not on your formulary?

If you are conducting a search and the drug you are searching for is not found, you should first contact Customer Service and ask if that drug is covered.

If you learn that that plan you are on or are interested in does not cover your drug, you have two options:

  • You may ask Customer Service to mail you a list of similar drugs that are covered by Fallon Health Weinberg-HMO SNP. When you receive the list, ask your provider to review it and to prescribe a similar drug that is covered by Fallon Health Weinberg-HMO SNP.
  • You may ask Fallon Health Weinberg to make an exception to cover your drug. Click here for information on how to request an exception to the formulary.

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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 are not on our formulary, or may be taking a drug that is on our formulary, but their ability to get it is limited. While the member talks to their doctor to decide if they should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take, we may cover the drugs in certain cases during the first 90 days of membership in our plan. Read our complete transition policy.

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What if my drug is not covered on a plan’s formulary?

Each plan that offers Medicare prescription drug coverage has a transition policy for people taking a drug that is not on our formulary. Read our complete transition policy.

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How do I request an exception to a formulary?

You can ask Fallon Health Weinberg to make an exception to our coverage rules. There are two exceptions that you can ask us to make.

  • You can ask us to cover your drug even if it is not on our formulary.
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Fallon Health Weinberg may limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

Generally, Fallon Health Weinberg will only approve your request for an exception if the alternative drugs included on the plan’s formulary or additional utilization restrictions would not 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 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.

Use the online Medicare Part D Coverage Determination form
- or -
Print a Medicare Part D Coverage Determination form (H2470_W_2015_11 Accepted 092614, pdf)

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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 Health Weinberg. Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not 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 may 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 Request for Payment of Medical Services 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 are 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 are 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 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. Your provider can call in your prescription directly to our mail-order pharmacy by calling 1-800-378-5697 (option 3), faxing it to 1-800-378-0323, or you can mail in the prescription to our mail-order pharmacy.
Our mail-order pharmacy offers four ways to order prescription refills:

  • You can order refills online at www.caremark.com. (This link takes you away from the Fallon Health Weinberg website.)
  • By calling toll-free at 1-866-412-5379 (TTY 711), you can access an automated refill system.
  • By mail: You can mail your prescription to:
    CVS Caremark
    PO Box 94467
    Palatine, IL 60094-4467
  • Physicians can fax in new or refill orders to the fax number above.

If you use the online service, be sure to sign up for the mail-order pharmacy’s refill reminder program at www.caremark.com. (This link takes you away from the Fallon Health Weinberg website.)
With this service, you’ll get convenient email notices from the mail-order pharmacy when it’s time to refill or renew a prescription.

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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 days. If the mail-order pharmacy expects a delay of more than 10 days, we will 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 (phone numbers are printed on the back cover of this booklet) 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.

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How do I obtain a prescription if a mail-order is delayed?

Our mail service employs state-of-the-art technology to track and monitor the status of prescription orders throughout the dispensing process. Each step of dispensing requires the identification of all associates involved in handling the order.

We generate a daily report which identifies orders that are delayed due to an eligibility issue, medication out of stock, physician call, etc. This report always identifies the oldest order in house, which gains the highest priority for resolution. We will call you to advise you of the reason for the delay and to determine if the medication is urgently needed. If necessary, we will ship the order via overnight delivery.

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What is Medication Therapy Management?

Medication Therapy Managment is a free service that is designed to help eligible members stay healthy while taking multiple prescription drugs. 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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Fallon Health Weinberg is an HMO plan with a Medicare contract and a coordination of benefits agreement with the New York State Department of Health. Enrollment in Fallon Health Weinberg depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits and/or copayments/coinsurance may change on January 1 of each year. Copays may vary based on the level of Extra Help you receive. Please contact the plan for further details. The Formulary and/or pharmacy network may change at any time. You will receive notice when necessary.You can have most prescriptions shipped to your home through our mail-order pharmacy. If your order does not arrive within 10 days, please call CVS/Caremark at 1-866-412-5379 (TRS 711).

H2470_W_2017_7 Approved 10182016
The information on this page was last updated on 10/1/2017.

Find a doctor

Looking for a doctor? Need to see if your current doctor is in our network?

Search online

Download the Provider and Pharmacy Directory (H2470_W_2017_26_r1_NM, pdf)

Contact us

Information before enrolling:
1-855-561-7248 (TTY 711)
8 a.m.–8 p.m., Monday–Friday
(Oct. 1–Feb. 14, seven days a week)

Customer Service:
1-855-561-7247 (TTY 711)
8 a.m.–8 p.m., Monday–Friday
(Oct. 1–Feb. 14, seven days a week)

Member information

2017 Summary of Benefits (H2470_W_2017_6_r1 Accepted 10152016) ►

2017 Evidence of Coverage (H2470_W_2017_1 Accepted 09122016, pdf) ►

About the Medication Therapy Management Program

Covered medications

Find a doctor

Medicare Part D forms

Request for Medicare Part D prescription drug coverage determination
Use this form to initiate a prior authorization request for your medication.

Request for a Medicare Part D appeal
Use this form to initiate an appeal for a denied medication.