OptumRx will be Fallon Health's new pharmacy benefits manager starting January 1, 2022.

A pharmacy benefits manager (PBM) is a company that we partner with to provide your prescription medication coverage and benefits. On January 1, 2022, Fallon Health will be changing our PBM from CVS Caremark to OptumRx. We are working to make this transition as smooth as possible for you, our members.

General questions

Q. Why are you making this change?

A. We are always looking for ways to provide you with the best possible care. We partner with other organizations that strive for the same things as we do. At this time, we believe a partnership with OptumRx is the best way to provide quality coverage and care to you.

Q. Will you still cover the same prescription drugs you do now?

A. We are not changing our list of covered medications (formulary) as a result of this change. However, we do review and update our formulary periodically to make sure we are offering you the safest and most appropriate medications. You can check your list of covered drugs on our online formulary tool.

Q. Will I pay more for my prescription drugs?

A. This change will not impact your prescription drug costs. However, if your plan was renewed recently, your prescription drug copayments, coinsurance and/or deductibles may have changed. You can check your Member Handbook/Evidence of Coverage or log into the MyFallon member portal to see your prescription drug coverage.

Q. Will my pharmacy network change? Can I still use the same pharmacy?

A: You will most likely be able to use the same pharmacy. The OptumRx pharmacy network is very similar to our current network, with only a few exceptions. To see if your pharmacy is in the OptumRx network, visit our online Pharmacy Finder.

Q. Do I need to do anything on January 1, 2022?

A: The first time you pick up a prescription after January 1, you must give your new Fallon Health ID card to the pharmacy. You may also want to give your new card to your doctor at your next appointment.

Q. What will happen if I don’t give my Fallon Health ID card to the pharmacy after January 1?

A. If you try to get a prescription medication after January 1 and you don't use your new member ID card at the pharmacy, you will be charged the full cost of your prescription at that time. If you give your new card to the pharmacy, the pharmacist will see that your prescription drugs are now covered by our new PBM, OptumRx.

Q. What if I didn’t use my Fallon Health ID card at the pharmacy and I paid out of pocket for my prescription? Can I get reimbursed?

A. Yes. If your prescription would normally be covered by your plan, you can request a reimbursement. 

Q: When will I receive my new Fallon Health ID card?

A. You will receive your new ID card before the end of 2021.

Q. Can I still use my CVS ExtraCare card when I go to CVS?

A. Yes, you can continue to use your CVS ExtraCare card at CVS retail stores. However, you will only receive the standard CVS ExtraCare discounts.

Mail order

Q. I currently get my prescriptions through CVS Mail Order. What do I need to do?

A. If you currently have refills left on your prescription, you simply need to sign up with OptumRx Home Delivery to continue to receive your prescription through mail order. To do so, starting on January 1, visit optumrx.com or call:

  • Fallon Medicare Plus and NaviCare members: 1-844-657-0494 (24 hours a day, seven days a week)
  • Community Care, Direct Care, Select Care and Preferred Care members: 1-844-720-0035 (24 hours a day, seven days a week)

If you no longer have any refills left on your mail-order prescription, or your prescription is for a controlled substance, you will need a new prescription from your provider. You can then sign up with OptumRx Home Delivery.

Q. I currently use mail order for a controlled substance. What do I need to do to keep getting it through mail order?

A. To continue getting your medication through mail order, you'll need a new prescription from your provider. You can then sign up with OptumRx Home Delivery starting January 1. Just visit optumrx.com or call:

  • Fallon Medicare Plus and NaviCare members: 1-844-657-0494 (24 hours a day, seven days a week)
  • Direct Care, Select Care and Preferred Care members: 1-844-720-0035 (24 hours a day, seven days a week)

Specialty pharmacy

Q. I currently get my prescriptions through CVS Specialty Pharmacy. What do I need to do?

A. If you're a Fallon Medicare Plus or NaviCare member, you don't need to do anything. You can continue to receive your prescriptions through CVS Specialty Pharmacy.

If you're a member of one of our other plans, you'll need to get your prescriptions through OptumRx Specialty Pharmacy after January 1. To get set up, visit specialty.optumrx.com or call 1-855-427-4682 after January 1 (24 hours a day, seven days a week).

Q. I currently get my Specialty medications through UMass, Tufts, Berkshire or one of the two fertility pharmacies (Freedom Fertility Pharmacy, Village Fertility Pharmacy). Do I need to do anything? 

A.  No, you don't need to do anything. You will continue to get your medications through those specialty pharmacies.

Prior authorizations

Q. I have an approved prior authorization for my medication. Do I need to do anything?

A. No, your prior authorization information will be automatically transferred to OptumRx. If you need a new authorization once your current one expires, your provider will need to request it through OptumRx.

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The information on this page was last updated on 10/21/2021.