Pharmacy exception process

Sometimes, your drug may not be on our formulary.  If the drugs on our formulary are not appropriate for you, there is a formulary exception process available. This process follows the standard prior authorization process, except where noted below.

Non-covered items 

Non-Formulary: 
Medications not on the formulary are considered non-formulary and are not covered. 

If your provider feels that the medications on our formulary are not appropriate for your condition, there is an exception request process available. Your prescriber must support the request by providing a statement that provides justification for supporting the need for the non-formulary drug to treat your condition, including a statement that all covered formulary drugs on any tier will be or have been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects. This request must be approved by Fallon Health before we will pay for the drug. Your attending provider should submit a prior authorization request to Fallon per the normal prior authorization process and request an exception request.

You or your prescribing physician may make an expedited exception request if exigent circumstances exist. Exigent circumstances exist when you are suffering from a health condition that may seriously jeopardize your life, health or ability to regain maximum function or when you are undergoing a current course of treatment using a non-formulary drug. You will be notified within 72 hours of receipt of information sufficient to begin our review for a standard request, or 24 hours of receipt of information sufficient to begin our review for an expedited request.

If you disagree with the decision on your standard or expedited exception request above, you may file an external exception request. To file a standard or expedited external exception request please contact Fallon Health at 1-800-333-2535 or email us at grievance@fallonhealth.org. We will forward your external exception request to an independent review organization for a review and determination. The same standards and time frames outlined above will apply to standard and expedited external review requests.

If approved, a non-formulary drug will incur a copay associated with your highest generic (if the drug is a generic) or brand (if the drug is a brand) copay tier.

Exclusions: 
Medications/conditions listed in your Evidence of Coverage under “Related Exclusions” are not a covered benefit.