Pharmacy prior authorizations

Prior authorization process

Fallon Health collaborates with CVS Caremark® (Fallon's Pharmacy Benefit Manager) and Magellan Rx Management to implement our prior authorization process. For all lines of business, CVS Caremark 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.  Magellan Rx Management reviews medical benefit drugs (physician-administered drugs, including home infusion).  

Learn more about our Medical Rx programFAQs | Webinar recording.

How to locate criteria and PA forms

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:
Prior authorization 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. 

Patient-administered drugs (pharmacy benefit)

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 CVS Caremark have made submitting PAs easy, quick, and convenient, resulting in near real-time decisions.* No faxes. No phone calls. The ePA tool is available at no cost to providers and their staff. CVS partners with CoverMyMeds & SureScripts making it easier for you to access ePA through your vendor of choice.

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.

To learn more and to register, go to info.caremark.com/epa. (You’ll need your NPI and DEA numbers.)

*May not result in near real-time decisions for all prior authorization types and reasons.

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

Plan name Phone Fax
Medicare
Part D plans and NaviCare 
  • Fallon Medicare Plus HMO
  • NaviCare HMO SNP and NaviCare SCO
  • Summit ElderCare®
1-866-239-4707 1-855-633-7673
Medicaid plans
  • Berkshire Fallon Health Collaborative
  • Fallon 365 Care
  • Wellforce Care Plan
1-866-643-5126 1-855-762-5204
Commercial plans
  • Direct Care
  • Fallon Medicare Plus Freedom
  • Select Care
  • Fallon Preferred Care PPO
  • Steward Community Care
1-866-772-9538 1-888-836-0730
Medicaid and Commercial plans – Specialty Drugs only
  • All Commercial and Medicaid plans
1-866-814-5506 1-866-249-6155
Medicaid and Commercial plans –
Opioid Program only
  • Commercial plans
  • Exchange plans
  • Medicaid plans
1-800-294-5979
1-855-582-2022
1-866-643-5126
1-866-217-5644
1-866-217-5644
1-866-217-5644

Physician-administered drugs (medical benefit)

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 Magellan Rx Management have made submitting PAs easy, quick, and convenient through the ih.magellanrx.com website.

  • Please click “Providers and Physicians” to get to the login page, or
  • “New Access Request-Provider” to request access.

Call or fax

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

Learn more about our Medical Rx programFAQs | Webinar recording.

Medicare glucose monitors and test strips

For Medicare members only, Fallon Health reviews Medicare glucose monitor and test strip requests. Please fax requests to 1-508-791-5101 or call 508-368-9825, option 5, option 2.

CVS Caremark is a registered trademark of CVS Pharmacy, Inc. Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members’ private health information.