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Code	Description	NDC	Brand Name Generic Name	Brand/ Generic/ Repackager	Dose/Strength	Status	Notes & Restrictions

Definition of Status

Icon	Status	Definition
	Medical benefit	Drugs that are covered under the medical benefit.

Definition of Restrictions

Icon	Restriction	Definition
	Home Infusion	Home Infusion is available for this drug.
	Important Information	Fallon Health limits coverage of hyaluronic acid derivatives to the following: Euflexxa, Synvisc, & Synvisc-One will be covered when submitted with an appropriate ICD-10 code, and quantity limits will apply. Please review the PSCE policy below for more information.
	Medical Drug Wastage Program	Beginning February 1, 2025, for our Community Care and ACO members, Fallon Health will be partnering with Prime Therapeutics to launch a medical drug wastage program. As part of the prior authorization process, Prime Therapeutics will require dose rounding for infused drug products to the nearest lowest vial size if within +/- 10% of the original prescribed dose ("the Recommended Dose") unless the medical necessity criteria are met (see below). Click here for medical necessity criteria: https://fm.formularynavigator.com/FormularyNavigator/DocumentManager/Download?clientDocumentId=zkCSb2aqO0yqXSB_h9FfkQ
	Post Service Claim Edits	This drug may be subject to post service claim edits depending on the member's plan. Click here for post service claim requirements for Commercial Exchange and ACO members:https://fm.formularynavigator.com/FormularyNavigator/DocumentManager/Download?clientDocumentId=q0rFBp8AKkCU0tq0MP4Vhw Click here for post service claim requirements for Medicare members: https://fm.formularynavigator.com/FormularyNavigator/DocumentManager/Download?clientDocumentId=EZuzlicOC0eJsGo5FQWdWg
	Preferred Drug for ACO plans only	This indicates preferred drugs for ACO plans only. In general, Fallon Health requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within therapeutic class.
	Prior Authorization	Fallon requires you (or your physician) to get prior authorization for certain drugs. This means that you will need to get approval from Fallon before you fill your prescriptions. If you don't get approval, Fallon may not cover the drug.
	Prior Authorization Form	Prior Authorization Form

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