Pharmacy benefit copay tiers and prior authorization for brand drugs
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Describes copayment structure for the 2025 HMO Silver A SG pharmacy benefit and the prior authorization/medical necessity expectations for brand-name drugs versus generics; applies to Health-New-England members in the plan described.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Rules
Coverage criteria for brand vs generic drugs
Covered with conditions based on tier and demonstration of medical necessity.
From benefit summary and mail order copay table.
Medical necessity must be documented; see examples below.
Examples provided by policy.
State substitution rules in Massachusetts require pharmacists to dispense generics unless prescriber indicates 'no substitution'.
Health New England will not approve a brand‑name drug when an FDA‑approved generic equivalent exists unless the provider demonstrates medical necessity. Requests for coverage of a brand product in this situation must include documentation showing why the generic is not appropriate (for example, intolerance, allergic reaction, or inadequate therapeutic response). This requirement reflects the plan’s tiered benefit structure and the expectation that lower‑cost, FDA‑approved generics be used when therapeutically equivalent.
Examples of situations that will not be covered without documented medical necessity include prescribing a brand‑name product when an FDA‑approved generic is available and no supporting documentation is provided. Commonly accepted reasons that may justify brand coverage — and therefore should be documented — are allergic reaction or intolerance to the generic, inadequate response to the generic, or failure of alternatives in the drug class. Absent such documentation, the use of the brand product is considered not medically necessary and may be denied.
Provider Requirements and Authorization Process
Prior Authorization Required
Prior authorization is required for brand-name drugs when medical necessity must be shown (for example, when an FDA-approved generic exists). Providers seeking coverage for a brand-name product should submit a completed drug request form and supporting documentation demonstrating medical necessity (for example, inadequate response or allergic reaction to the generic(s), or failure of alternatives in the drug class).
- Submit a completed drug request form and fax to Health New England for review.
- Include supporting documentation demonstrating medical necessity (e.g., inadequate response or allergic reaction to generic(s); failure of alternatives in the drug class).
- If medical necessity is not demonstrated for a brand-name drug when an FDA-approved generic exists, coverage for the brand product may be denied.
Expectation of Failure of Alternatives
Medical necessity examples include inadequate response or allergic reaction to generic(s) and failure of alternatives in the drug class.
Required Documentation for Brand-Name Drug Requests
Providers must submit a drug request form and supporting documentation demonstrating medical necessity for brand-name drug requests. Documentation should describe prior trials of the FDA-approved generic(s) and the clinical reason why the brand product is necessary.
Brand Coverage Conditional on Medical Necessity
Failure to demonstrate medical necessity for a brand-name drug when an FDA-approved generic exists may result in denial of coverage for the brand product.
Clinical and Regulatory Background
Generic drugs are FDA‑approved products that contain the same active ingredients as the brand‑name drug and are considered as safe and effective as their brand counterparts. They are typically lower cost and are the preferred option under the plan’s pharmacy tiers. Note that in Massachusetts pharmacists are required to dispense the generic product unless the prescriber writes "no substitution" on the prescription. When a brand is requested despite an available generic, the provider must document medical necessity to support coverage.
Tier Definitions and Terms
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