Pharmacy Benefit Tier Definitions and Copay Structure (2025)
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Defines Health New England's 2025 pharmacy benefit tier options (3-tier and 5-tier) including copay amounts, tier definitions, and prior authorization/medical necessity rules for brand drugs; applies to HMO Focus LG members.
No material clinical or coverage changes in this revision.
Coverage Criteria and Tier Rules
3-Tier Coverage
Covered subject to tier-based copays and medical necessity for certain brand drugs.
Example member copays: $10/$45/$75 or $10/$50/$100 depending on plan variant; mail order copays examples: $20/$90/$225 or $20/$100/$300.
5-Tier Coverage
Covered subject to tier-based copays; specialty drugs assigned to Tier 4 or Tier 5 with no mail order for specialty.
Example member copays: $15/$50/$100/$150/$250; corresponding mail order examples show higher amounts and specialty excluded from mail order.
Mail order is not available for Specialty drugs; specialty medications are managed through specialty pharmacy channels and are assigned to higher tiers in the benefit design rather than being offered via the mail order benefit.
Health New England does not waive or reduce copays for Brand/Non-Formulary drugs; these medications remain covered but members are responsible for the higher copay applicable to that tier.
Provider Requirements and Authorization
Prior authorization required for brand when generic exists
Prior authorization is required when a prescriber requests a brand‑name drug that has an FDA‑approved generic equivalent; submit a drug request form and supporting documentation of medical necessity for review.
- Request prior authorization via the drug request form and fax to Health New England.
- Include documentation showing medical necessity when requesting the brand instead of the generic.
Step/therapeutic alternatives must be tried or documented
Providers are expected to document failure or intolerance to lower‑tier or class alternatives before brand/non‑formulary coverage is approved; examples of medical necessity include inadequate response or allergic reaction to generics or failure of alternatives in the drug class.
- Document inadequate response or allergic reaction to the generic(s).
- Document failure of therapeutic alternatives in the drug class prior to approving brand agents.
Submit drug request form and fax medical‑necessity documentation
When requesting a brand override, the provider must submit the completed drug request form and fax documentation of medical necessity (for example, inadequate response or allergic reaction to the generic(s) and failure of alternatives in the drug class).
- Include clinical notes or test results demonstrating inadequate response or allergy to the generic(s).
- Fax the drug request form and all supporting documentation to Health New England for review.
Brand with generic covered only if medical necessity shown
Coverage of brand‑name drugs that have FDA‑approved generics requires demonstration of medical necessity; without such documentation coverage may be denied or the member may be subject to higher copays.
- Medical necessity examples: inadequate response or allergic reaction to generics, failure of alternatives in the drug class.
- Health New England covers brand name drugs with FDA‑approved generics only if medical necessity has been shown.
Tier Definitions
Initial Authorization Criteria for Brand Overrides
Initial Authorization for Brand Overrides
When requesting coverage of a brand-name drug that has an FDA‑approved generic, coverage is granted only when ALL of the following are met:
Medical Necessity for Brand with Generic
- Examples of medical necessity (one or more):: Inadequate therapeutic response to the FDA‑approved generic equivalent(s).
Documented lack of efficacy with generics.
- Allergic reaction or intolerance to the FDA‑approved generic equivalent(s).
Documented adverse reaction preventing use of generics.
- Failure of appropriate alternatives in the same drug class.
Trial and failure of lower‑tier or therapeutic alternatives as applicable.
Request must be submitted via the drug request form with supporting clinical documentation for review.
Step Therapy and Documentation Requirements
| Requirement | Details |
|---|---|
| Documentation of failure or intolerance to lower-tier alternatives | |
| Provider must submit a drug request form and fax supporting documentation demonstrating medical necessity (examples include inadequate response or allergic reaction to generics, and failure of alternatives in the drug class). |
Mail Order and Site Restrictions
Mail order copays differ by tier; specialty drugs not available by mail
Mail order copays differ by tier (see plan copay tables); specialty drugs are not available via mail order.
- 3‑tier example mail order copays: Generic/Brand Formulary/Brand Non‑Formulary = $20/$90/$225 or $20/$100/$300.
- 5‑tier example mail order copays: Generic/Brand Formulary/Brand Non‑Formulary = $30/$100/$300.
- Specialty drugs (Tier 4/5) are excluded from mail order.
Background and Rationale
This document describes the payer's pharmacy benefit design and tier definitions rather than clinical treatment guidance. It defines tier categories used for cost-sharing: Generic (Tier 1), Brand Formulary (Tier 2), Brand Non-Formulary (Tier 3), Formulary Specialty (Tier 4), and Non-Formulary Specialty (Tier 5), and explains that coverage and member copays are determined by those tiers.
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