CurrentHealth-New-EnglandPolicy N/A

Pharmacy benefit tiers and copay structure

Defines Health New England's 3-tier and 5-tier pharmacy benefit options, copay amounts (including mail order where applicable), and tier definitions; affects HMO Focus LG members and providers submitting pharmacy claims or prior authorizations in NC and MA context.

Policy Summary

PayerHealth-New-England

PolicyPharmacy benefit tiers and copay structure

Policy CodePolicy N/A

Change TypeMinor update / informational

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionSubmit a drug request form with supporting documentation of medical necessity when requesting coverage of a brand drug that has an FDA-approved generic.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

33-tier option

55-tier option

$10/$45/$75example copays (3-tier)

$15/$50/$100/$150/$250copays (5-tier)

Not allowedspecialty mail order

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Coverage Criteria

Brand with Generic Available — Conditional Coverage

Covered when ALL of the following are met:

Medical necessity for brand when generic exists: Provider must submit a drug request form with documentation showing inadequate response or allergic reaction to the generic(s) AND failure of alternatives in the drug class.

Prior authorization may be required; submit drug request form and fax supporting documentation of medical necessity.

Health New England does not waive or reduce copays for Brand/Non-Formulary drugs. Brand Non-Formulary medications remain covered but are subject to a higher copay level and no exception to the copayment is offered for these tier 3 drugs.

There are no standalone Not Medically Necessary (NMN) declarations in this policy beyond the requirement that coverage of a brand-name drug with an available generic is contingent on documented medical necessity. Requests for brand coverage when a generic exists must follow the medical necessity process (see prior authorization and documentation requirements) rather than being categorically labeled NMN.

Provider Actions & Requirements

Prior Authorization

Brand coverage when a generic exists

Health New England covers brand-name drugs that have FDA‑approved generic equivalents only when medical necessity is demonstrated. Pharmacy benefit tiers favor generics; pharmacists in Massachusetts must dispense a generic unless the prescriber writes 'no substitution'. If a brand is requested when a generic is available, prior authorization may be required and the provider must document why the brand is clinically necessary.

Affected: brand-name drugs with available FDA-approved generics
Massachusetts pharmacy substitution law applies: prescriber must indicate 'no substitution' for brand dispensing

Documentation Required

Medical necessity documentation required for brand requests

Requests for a brand drug when a generic exists must include documentation of medical necessity. Acceptable documentation includes clinical rationale such as inadequate response, intolerance, or allergic reaction to the generic(s), or failure of formulary alternatives within the same drug class. Attach relevant clinical notes, prior trial dates, and results to the prior authorization request.

Documented trial of generic(s) with dates and clinical outcomes
Evidence of intolerance or allergy to generic(s)
Clinical rationale for why alternatives were unsuitable

Step Therapy

Step therapy implications for brand requests

If the formulary includes step therapy or formulary alternatives, prescribers should follow the required step sequence before a brand will be approved. A prior authorization request for a brand should state which step-therapy steps were attempted and the clinical outcome; failure to show that step therapy was followed may lead to denial.

Include dates and outcomes of attempted step-therapy agents or formulary alternatives
If step therapy was bypassed, document clinical justification

Denial Risk

Denial risk and submission requirements

Failure to provide required documentation (medical necessity, step-therapy attempts, or 'no substitution' order when applicable) may result in denial of the brand drug request. Providers may be required to submit a completed drug request/prior authorization form and supporting medical records for review.

Denial risk if medical necessity or step-therapy documentation is not provided
Submit completed drug request/prior authorization form and supporting records

Formulary Tier Definitions

Generic / Tier 1

DefinitionGeneric/Tier 1: Approved by the FDA; contains the same active ingredients as brand-name drugs; as safe and effective and usually lower cost.

Massachusetts dispensing ruleIn Massachusetts, pharmacists are required to fill generic drugs unless the prescriber writes 'no substitution' on the prescription.

Cost implicationTypically lowest copay tier compared with brand and specialty tiers.

Brand Formulary / Tier 2

DefinitionBrand Formulary/Tier 2: Brand drugs marketed under a trademarked name and selected for formulary based on review of relative safety, effectiveness, and cost.

Copay positionCopay for Brand/Formulary drugs is higher than generic drugs but lower than Brand/Non‑Formulary drugs.

Site-of-Care / Dispensing Notes

Billing Rule

Specialty drugs not available by mail order

Specialty drugs cannot be dispensed via mail order; arrange specialty dispensing through appropriate channels (retail specialty pharmacy per plan rules).

Mail order is not available for Specialty drugs per the pharmacy benefit description.

Background

This policy defines the pharmacy benefit tiers and associated copay structure for Health New England members. Under the 5-tier option, Generic / Tier 1 are FDA-approved generics that are as safe and effective as brand-name drugs and typically cost less; pharmacists in Massachusetts must dispense generics unless the prescriber indicates 'no substitution'. Brand Formulary / Tier 2 includes brand drugs selected for formulary based on safety, effectiveness, and cost and carry a higher copay than generics but lower than non-formulary brand. Brand Non-Formulary / Tier 3 are brand-name drugs not selected for the formulary; these are covered at a higher copay and, per policy, copays for Brand/Non-Formulary drugs are not waived or reduced. The document also describes specialty tiers for higher-cost products, and notes that specialty drugs are not available via mail order.