The formulary below is a listing of prescription drugs that are covered by NaviCare HMO SNP and NaviCare SCO. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary and the prescription is filled at a network pharmacy. Some covered prescription drugs have additional requirements and limits: prior authorization, step therapy, limited access (only available at certain pharmacies) and quantity limits. The printed formulary was last updated on August 17, 2012. It is subject to change at any time.
Prior authorization and step therapy
Fallon Community Health Plan (FCHP) requires your physician to get prior authorization for certain drugs. This means that you will need to get approval from FCHP before you fill your prescriptions. If you don’t get approval, NaviCare may not cover the drug. If a drug requires a prior authorization, you'll see a "PA" next to the drug in the online drug formulary search. You can click on the "PA" symbol to see the prior authorization criteria for that medication. Step therapy
In some cases, FCHP requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, NaviCare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, NaviCare will then cover Drug B.
Drugs with step therapy requirements:
Changes to the list of covered medications
You may view the PDF documents below to see if there are changes to the 2013 NaviCare HMO SNP list of covered medications. If there are no documents listed below, then there are currently no changes to the list of covered medications.
NaviCare HMO SNP formulary changes - 4/1/2013 (H9001_N_2013_252 File&Use 03202013, pdf)
My drug isn't on the covered medications list. What can I do?
Drug transition policy
As a new member within the first 90 days of membership, you may be taking drugs that are not on our formulary, or you may be taking a drug that is on our formulary but your ability to get it is limited. Or, you may be a member who is continuing as our member, but the list of drugs that we cover has changed at the beginning of the year. Or, you may be taking a drug that is on our formulary, but your ability to get it is limited. This policy explains how we can help you transition your drugs.
Request for Medicare prescription drug coverage determination form (SCO_2012_299 EOHHSApproved 05222012, pdf)
Use this form for you to request an exception or coverage determination. You can also access an online version of this form.
Medicare Part D coverage determination request form
The provider who prescribes your drugs may use this form to request an exception or coverage determination.
To request a coverage determination for an over-the-counter drug, please contact Enrollee Services at 1-877-700-6996
(TTY users, please call TRS Relay 711), Monday through Friday, from 8 a.m. to 8 p.m. (From October 1 through February 14, we're available seven days a week.)
Other important information about medications
Medication Therapy Management Program
The Medication Therapy Management (MTM) Program is a free service that we offer through NaviCare, if you qualify. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate, but it is recommended that you take full advantage of this covered service if you are selected. Learn more about the Medication Therapy Management Program »
NaviCare is a Coordinated Care plan with a Medicare contract and a contract with the Massachusetts Medicaid program. NaviCare is a voluntary program in association with MassHealth/EOHHS and CMS.
Benefits, formulary and pharmacy network may change on January 1 each year. Limitations and restrictions may apply . The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
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H9001_N_2013_15 Approved 10292012
The information on this page was last updated on 10/1/2012.