CurrentHealth-New-EnglandPolicy N/A

2025 Pharmacy Benefit for HMO Gold A SG

Defines copay tiers (Generic/Tier 1, Brand Formulary/Tier 2, Brand Non-Formulary/Tier 3), mail order copays, deductible application for Brand Non-Formulary drugs, pharmacist substitution rule in Massachusetts, and prior authorization/medical necessity requirement for brand-name drugs with generic equivalents.

Policy Summary

PayerHealth-New-England

Policy2025 Pharmacy Benefit for HMO Gold A SG

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProvider must submit a drug request form and fax it to Health New England with documentation demonstrating medical necessity to obtain coverage for brand drugs with FDA-approved generics.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

3Copay Tiers

$25/$45/$75Retail Copays (G/BF/BNF)

$50/$90/$225Mail Order Copays (G/BF/BNF)

PABrand with Generic Equivalent

Coverage Summary

Defines three copay tiers: Generic/Tier 1, Brand Formulary/Tier 2, and Brand Non-Formulary/Tier 3; retail copays are $25/$45/$75 respectively and mail order copays are $50/$90/$225. The Plan Deductible applies to Brand Non-Formulary drugs. In Massachusetts pharmacists are required to dispense generics unless the prescriber writes "no substitution" on the prescription. Brand-name drugs that have FDA-approved generics are covered only when medical necessity is demonstrated and a prior authorization request (drug request form faxed to Health New England) with supporting documentation is submitted.

Applicable Codes & Copay Tiers

Copay tiers and mail order copays (plan-level pricing)mixed

Tier 1	Generic copay: $25 (mail order generic: $50)
Tier 2	Brand Formulary copay: $45 (mail order brand formulary: $90)
Tier 3	Brand Non-Formulary copay: $75 (mail order brand non-formulary: $225); Plan Deductible applies to Brand Non-Formulary drugs

Copay tiers and mail order copays (plan-level pricing)mixed

Tier 1	Generic copay: $25 (mail order generic: $50)
Tier 2	Brand Formulary copay: $45 (mail order brand formulary: $90)
Tier 3	Brand Non-Formulary copay: $75 (mail order brand non-formulary: $225); Plan Deductible applies to Brand Non-Formulary drugs

Copay & Mail-Order Thresholds

Copay - Generic (Tier 1)$25

Copay - Brand Formulary (Tier 2)$45

Copay - Brand Non-Formulary (Tier 3)$75

Mail Order Generic$50

Mail Order Brand Formulary$90

Mail Order Brand Non-Formulary$225

Provider Actions & Billing Rules

Prior Authorization

Prior authorization required for brand-name drugs with generic equivalents

Provider must submit a drug request form and fax it to Health New England with documentation demonstrating medical necessity (e.g., inadequate response or allergic reaction to generics, or failure of alternatives in class) to obtain coverage for brand drugs with FDA-approved generics.

Documentation Required

Document medical necessity

Documentation must support medical necessity criteria such as inadequate response, allergic reaction to generics, or failure of alternatives in the drug class and be included with prior authorization submission. Example supporting documents: clinical notes describing inadequate response, allergy testing or reaction records, medication history showing trials and failures of alternatives in the class.

Clinical notes documenting inadequate response to generic(s)
Records of allergic reaction to generic(s)
Medication history showing failure of alternatives in the drug class

Billing Rule

Deductible applies to Brand Non-Formulary

Plan deductible applies to Brand Non-Formulary drugs; ensure deductible status when processing claims and verify member deductible has been met or applied for Brand Non-Formulary purchases.

Billing Rule

Pharmacist substitution rule (Massachusetts)

In Massachusetts, pharmacists are required to dispense generic drugs unless the prescriber writes 'no substitution' on the prescription; ensure dispensing follows state substitution laws when processing and billing prescriptions.

Policy Background & Definitions

This document outlines the 2025 pharmacy benefit copay structure for the HMO Gold A SG plan, specifying the Generic, Brand Formulary, and Brand Non-Formulary tiers and associated retail and mail-order copays. It also describes the conditions under which brand-name drugs that have FDA-approved generic equivalents may be covered — namely when medical necessity is shown and prior authorization is obtained.

Generic/Tier 1: Approved by the FDA; contain the same active ingredients as brand drugs, are as safe and effective, and usually cost less.

Brand Formulary/Tier 2: Brand/formulary drugs marketed under a trademarked name and selected based on safety, effectiveness and cost; copay is higher than generics but lower than non-formulary brands.

Brand Non-Formulary/Tier 3: Brand name drugs not on the formulary; covered at the highest copay and the plan deductible applies. Coverage of brand-name drugs with FDA-approved generics requires demonstration of medical necessity and prior authorization.

Clinical Evidence

No clinical-trial evidence or external citations were provided in the brief. Medical necessity for covering brand-name drugs with FDA-approved generics is defined operationally for prior authorization purposes and may include inadequate response to the generic(s), allergic reaction to the generic(s), or failure of alternatives in the drug class.