Pharmacy Services
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Defines Health-New-England's pharmacy benefit programs, formulary management, prior authorization, step therapy, quantity limits, specialty and compounded medication handling, and network/mail-order policies for members and providers.
No material clinical or coverage changes in this revision.
Coverage and Program Criteria
Program-level medical necessity criteria
Covered when ALL of the following administrative and clinical program requirements are met:
General requirements
- Prior authorization triggers: Medication is not covered, being used for an off-label indication, or being used for a new indication not yet reviewed by HNE.
Provider should request prior authorization from HNE; lack of prior authorization may result in non-coverage.
- Step therapy: Member must try specified first-line drugs before alternative drugs are covered unless prior authorization documents medical necessity to bypass step therapy.
See HNE Step Therapy Program and submit prior authorization to override.
- Quantity limits: Coverage is subject to quantity limits based on FDA recommendations and generally accepted pharmaceutical guidelines.
Refer to the HNE formulary for specific quantity limits and quantity-based copays.
Excluded medications are those listed as Excluded Medications on the HNE formulary and are not covered. For the current list and details, providers should refer to the HNE formulary at http://healthnewengland.org/pharmacy/find-medication or contact HNE Member Services.
HNE does not cover new-to-market medications during the six-month Clinical Review Period following FDA approval. Depending on the member's plan, a drug approved during this period may be subject to a 50% cost-share. Medical exceptions may be granted, but if a later determination excludes the drug from coverage, coverage may be rescinded for the member.
Provider Requirements, Prior Authorization, and Appeals
Prior authorization and medical exception submission
Providers must request prior authorization when a medication is not covered, is being used for an off‑label indication, or is being used for a new indication that has not yet been reviewed by HNE. To obtain coverage for a non‑covered brand name drug, the provider must submit a prior authorization request that includes medical necessity rationale for a medical exception; if approved the non‑covered drug may be approved at the highest copay level and quantity limits may be applied at the reviewer’s discretion. See the HNE formulary or contact HNE Member Services for specific prior‑approval requirements.
- Prior authorization required for: not‑covered drugs, off‑label use, or new indications not yet reviewed by HNE.
- Medical exception for a non‑covered brand requires submission of medical necessity rationale by the provider; approvals may carry the highest copay and quantity limits.
Step Therapy: try first‑line drugs or request PA to override
HNE’s Step Therapy program requires members to try specified first‑line medications before HNE will cover alternative drugs for the same condition. If it is medically necessary for a member to receive a Step Therapy drug before trying a first‑line agent, providers should request prior authorization from HNE to bypass step therapy.
- Member must try first‑line drugs before alternatives are covered.
- Request prior authorization to override step therapy when medical necessity supports bypassing first‑line therapy.
Retrospective authorization (retroauthorization) process
If therapy began before a prior authorization was submitted, providers may request retroauthorization by contacting MagellanRx for approvals up to 60 days after therapy initiation; for retrospective requests beyond 60 days, providers must contact HNE Member Services.
- To request up to a 60‑day retroauthorization, contact MagellanRx at (800) 424‑8325 (Mon–Fri, 9 a.m.–6 p.m. ET).
- For retrospective requests beyond 60 days after the authorization approval date, contact HNE Member Services at (413) 787‑4004 or (800) 310‑2835, TTY 711.
Non‑coverage risk if prior authorization or guidelines not met
Failure to obtain required prior authorization or to meet program clinical guidelines for medications that belong to HNE management programs may result in non‑coverage of the drug.
- Refer to the HNE formulary or HNE Member Services for program membership and required clinical guidelines before dispensing.
Background and Rationale
HNE's specialty medication program covers therapies used for complex conditions (for example, cancer, multiple sclerosis, and rheumatoid arthritis) that often require special handling, storage, or administration and may be managed through specialty pharmacy or infusion center channels. The Pharmacy & Therapeutics committee evaluates these agents for safety, efficacy and cost, and program rules (such as prior authorization, step therapy, quantity limits, and the six-month Clinical Review Period for newly approved drugs) apply to specialty medications.
Key Definitions
Step Therapy Rules
| Step | Requirement | Override / Prior Authorization |
|---|---|---|
| 1 | Member must try specified first-line (first‑line) medications for the condition before HNE will cover alternative medications. | Prior authorization is required to override step therapy when medical necessity dictates use of a non‑first‑line drug; providers should submit a prior authorization request to HNE. |
Quantity Limits and Maintenance Supply
Site-of-Care and Dispensing
Use MagellanRx for pre‑service authorizations and site‑specific infusion management
MagellanRx manages injectable and infusion medications for HNE (pre‑service prior authorizations and post‑service claim edits). Providers must determine whether a medication is part of the Magellan program and use MagellanRx for pre‑service prior authorizations when required.
- To check program participation, visit http://healthnewengland.org/pharmacy/find-medication or call HNE Member Services at (413) 787-4004 or (800) 310-2835, TTY 711.
- For pre‑service prior authorizations access the MagellanRx secure site at http://ih.magellanrx.com/ or call MagellanRx at (800) 424-8325 (Monday–Friday, 9 a.m.–6 p.m. Eastern).
Fill maintenance meds via participating retail (Access 90) or mail order
Maintenance medications may be filled at participating retail pharmacies under the Access 90 program for up to a 90‑day supply (copay applies per 30‑day supply), or obtained through HNE's mail order vendor for up to a 90‑day supply; providers and patients should use participating pharmacies or mail order per member plan rules.
- Access 90 applies only at participating retail pharmacies and does not apply to specialty vendor fills or if prohibited by law.
- For participating pharmacy listings or mail order information visit the HNE Access 90 page or the mail order pharmacy page, or call HNE Member Services at (413) 787-4004 or (800) 310-2835, TTY 711.
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