To order additional copies, please call Massachusetts Medical

and Commonwealth Care Plan Type I members and three-tier formulary design
for Commonwealth Care Plan Types II and III. A prescription is required for all
prescription and covered over-the-counter (OTC) medications. A list of the covered
OTC medications can be found at www.bmchp.org on the Pharmacy Homepage
under Pharmacy Benefits.
MassHealth and Commonwealth Care Plan Type I members:
Tier I* — Select generic and covered OTC medications
iv
Tier II — All other generic and covered OTC medications, brand-name medications
*Copayments for most generic and covered over­the­counter medications (with a prescription)
and all brand­name medications will be $3 EXCEPT for certain medications
members may take for high blood pressure, high cholesterol, or diabetes. The copayments
for these will be $1.
Commonwealth Care members plan type II and III:
Tier I — Generic and covered OTC medications
Tier II — Preferred medications
Tier III — Non-preferred medications
Certain medications require prior authorization (PA), step therapy (ST) or
quantity limitation (DL) as indicated in this guide. Other programs include the
Mandatory Generic Substitution Program for brand name drugs with AB-Rated
generic equivalents, and the New-to-Market Program (NTM) for recently FDAapproved
drugs, each of which requires preauthorization review. The Specialty
Pharmacy Program manages the dispensing of certain high-cost medications.
Refer to the website (www.bmchp.org) for formulary information, pharmacy
network, mail order pharmacy benefits, clinical guidelines for medication coverage,
and prior authorization forms. For additional information, please call BMCHP’s
pharmacy benefits manager, informedRx, at (800) 510-8980.
Fallon Community Health Plan (FCHP)
This edition of the Massachusetts Outpatient Formulary Guide lists the most commonly
prescribed medications that are available to Fallon members at the time
of printing. If a medication is not on this list, please call the Fallon Community
Health Plan Department of Pharmacy Services at (866) 275-3247, ext. 5, for
further clarification.
The following information is for the most common commercial formulary. There
are different formularies for Medicare members and the closed formulary. Please see
the end of this legend for the FCHP website to get the entire list of formularies and
medications listed in them.