Pharmacy benefit copay tiers and prior authorization for brand-name drugs
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Defines copay tiers, mail-order copays, deductible application for non-formulary drugs, and prior authorization / medical necessity requirements for brand-name prescriptions under the Health-New-England 2026 Pharmacy Benefit for HMO Silver A SG plan. Affects plan members and prescribers/pharmacists dispensing covered outpatient prescription drugs.
No material clinical or coverage changes in this revision.
Coverage Criteria for Brand and Non-Formulary Drugs
Brand coverage requiring medical necessity
Coverage of brand-name drugs that have FDA-approved generic equivalents is conditional when ALL of the following are met:
Medical necessity for brand when generic exists
- Examples of acceptable documentation: Inadequate response to generic(s); allergic reaction to generic(s); failure of alternatives in the drug class
Document one or more of these clinical reasons on the drug request form and fax to Health New England for review.
The pharmacy benefit uses three copay tiers: Generic/Tier 1, Brand Formulary/Tier 2, and Brand Non‑Formulary/Tier 3. Retail copays are $30 / $55 / $75 (Generic / Brand Formulary / Brand Non‑Formulary) and mail order copays are $60 / $110 / $225. Plan deductible applies to Non‑Formulary drugs. Brand name drugs that have FDA‑approved generic equivalents are covered at the brand tier only when medical necessity has been shown; otherwise they are subject to non‑formulary handling and deductible application as stated above.
If a provider requests coverage of a brand‑name drug when an FDA‑approved generic equivalent is appropriate, and no medical necessity documentation is provided, the use of the brand will be considered not medically necessary for coverage at the brand tier. In such cases coverage at the brand/formulary tier will not be granted unless the required documentation demonstrating medical necessity (for example, inadequate response or allergic reaction to the generic(s), or failure of alternatives in the drug class) is submitted.
Provider Requirements and Prior Authorization
Prior Authorization Required
Prior authorization is required for brand-name drugs when a generic equivalent exists or when the requested brand drug is non‑formulary. To request prior authorization, complete the Health New England drug request form and fax it to the number listed on the member's ID card or the Health New England provider resources page. Include supporting medical records that demonstrate medical necessity.
- Submit completed drug request form and all supporting documentation by fax for review.
- Include member name, member ID, drug name, dosage, and prescribing provider contact information on the request form.
Medical Necessity Documentation (Brand Drugs)
Health New England requires documentation of medical necessity to cover brand-name drugs when FDA‑approved generics are available. Medical necessity may include inadequate response to the generic, documented allergic reaction or intolerance to the generic(s), or failure of therapeutic alternatives in the same drug class. If medical necessity is not demonstrated, the request may be denied and the member may be responsible for the higher brand cost share.
- Examples of acceptable documentation: clinical notes describing inadequate response, allergy documentation, prior trial records of alternative agents in the class.
- If alternatives have not been tried, document clinical rationale why alternatives are inappropriate or unsafe.
Step Therapy / Failure Requirements
A step/failure requirement applies for coverage of many brand drugs that have lower‑cost generics or formulary alternatives. Providers must document trials and failures of the required generic or formulary agents before a brand product will be approved, unless contraindicated or clinically inappropriate.
- Document prior trials including drug name, dates of therapy, dose, and reason for failure (e.g., lack of efficacy, adverse reaction).
- If a required step is contraindicated, provide clinical justification on the request form.
Denial Risk When Medical Necessity Not Shown
If medical necessity or required step‑therapy documentation is not provided, the request for the brand‑name drug may be denied. Failure to supply the drug request form and supporting records (trial history, allergies, clinical rationale) increases denial risk and may delay therapy.
- Denials may occur when: no prior trial of required generics is documented; allergy/intolerance is not substantiated; or the drug request form is incomplete.
- To avoid denials, ensure the request form is fully completed and include pertinent clinical records with the faxed submission.
Tier Definitions
Policy Background
This document is administrative and defines the pharmacy benefit design and authorization expectations for the plan. It does not provide disease‑specific clinical guidance. Providers seeking brand coverage when a generic exists must follow the prior authorization process by completing a drug request form and faxing it to Health New England with supporting clinical documentation of medical necessity. Examples of acceptable reasons include inadequate response to generic(s), allergic reaction to generic(s), or failure of alternatives in the drug class.
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