Pharmacy benefit copay tiers and brand drug prior authorization
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Defines copay tiers, mail-order copays, and prior authorization expectations for brand-name drugs under the 2026 Pharmacy Benefit for HMO Gold A SG plan; affects prescribers, pharmacists, and members of this HMO plan in applicable states.
No material clinical or coverage changes in this revision.
Coverage criteria for brand vs generic drugs
Brand drug medical necessity criteria
Covered when ALL of the following are met:
Medical necessity includes, but is not limited to: inadequate response or allergic reaction to the FDA‑approved generic(s), and failure of alternatives in the drug class.
This policy does not list separate explicit exclusions beyond the standard coverage hierarchy for pharmacy benefits. Coverage follows the plan’s tier structure: Generic/Tier 1, Brand Formulary/Tier 2, and Brand Non‑Formulary/Tier 3, and any limits or requirements are applied within that hierarchy. Where a brand‑name drug has an FDA‑approved generic equivalent, coverage of the brand is governed by the medical necessity requirements described in this policy rather than a standalone exclusion.
When an FDA‑approved generic equivalent exists, a brand‑name product is not treated as a preferred option and will not receive lower tier cost sharing absent justification. In other words, brand drugs with available generics are covered only when medical necessity is demonstrated; providers must submit supporting documentation (for example, evidence of inadequate response or allergic reaction to the generic) to secure coverage at non‑standard tiers.
Prior authorization, documentation, and step expectations
Prior Authorization Required
Prior authorization is required when a Brand Non‑Formulary drug is requested in place of an available generic. Submit a completed drug request/prior authorization form and supporting clinical documentation to Health New England for review prior to dispensing when the prescriber is requesting a brand product despite an FDA‑approved generic equivalent.
- Submit requests using the Health New England drug prior authorization form.
- Fax or submit supporting records as instructed on the form; do not dispense assuming retroactive approval.
Step Expectations for Brand Coverage
Coverage of a requested brand product generally requires documented failure, intolerance, or contraindication to the generic equivalent(s) and reasonable trial of other class alternatives where applicable. The prescriber must describe prior trials and responses; approvals are made only when Medical Necessity is demonstrated.
- Document trial of FDA‑approved generic(s) for the same indication with dates, dose, duration, and clinical response.
- If the member had an allergic reaction or intolerance to the generic, include details and supporting clinical notes.
- If step therapy within the drug class applies, document trials of preferred alternatives and outcomes.
Documentation to Support Brand Request
Provide clinical documentation that supports medical necessity for a Brand Non‑Formulary request. Adequate documentation expedites review and reduces risk of denial.
- Relevant medical history and indication for therapy.
- Medication history showing generic trials (drug name, dose, start/stop dates) and reason for discontinuation (lack of efficacy, adverse event, contraindication).
- Laboratory or diagnostic results when relevant to the request.
- Provider clinical rationale explaining why the brand product is necessary over the generic, including clinical references if available.
Brand Non‑Formulary Prior Authorization Risk
Requests for Brand Non‑Formulary drugs without adequate documentation of medical necessity (prior trials, intolerance, or contraindication to generics and class alternatives) are at high risk for denial. If Medical Necessity is not established, coverage will be denied and the member will be responsible for the full cost.
- Denials are likely when the PA form is incomplete or lacks medication history.
- Consider prior authorization denial appeal instructions if additional evidence becomes available.
Step therapy requirements for brand approvals
| Requirement | Details |
|---|---|
| Documentation of failure or intolerance to FDA‑approved generic(s) | |
| Medical necessity must document inadequate response or allergic reaction to the generic(s); prior inadequate response or allergy supports approving a brand when generics exist. | |
| Documentation of failure of alternatives in the drug class | |
| Medical necessity may include failure of other agents in the same drug class prior to approving a brand-name product. | |
| Prior authorization submission requirement | |
| Prescriber must submit a drug request form and supporting documentation (medical necessity) to Health New England for review. |
Key plan drug-tier definitions
Policy background and scope
This document governs the pharmacy benefit cost sharing structure and explains when a brand‑name drug that has an FDA‑approved generic may be covered. Brand Non‑Formulary/Tier 3 products are covered at the highest copay level, and Health New England covers brand‑name drugs that have FDA‑approved generic equivalents only if medical necessity has been shown. Prior authorization is required for such brand requests; the prescriber must submit a drug request form and supporting documentation demonstrating medical necessity (for example, inadequate response or allergic reaction to the generic, or failure of alternatives in the drug class).
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