Pharmacy benefit copays and tiering for HMO Silver HDHP SG
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Defines copay tiers, mail order copays, deductible applicability, and prior authorization expectations for prescription drugs under the HMO Silver HDHP SG plan; affects providers prescribing and pharmacists dispensing medications for Health-New-England members in the plan.
No material clinical or coverage changes in this revision.
Coverage Conditions and Limits
Coverage conditions
Covered when plan rules for tiering and medical necessity are met:
copay amounts and deductible applicability govern coverage
applies to dispensing unless prescriber specifies brand by 'no substitution'
Prior authorization required with documentation of medical necessity; provider must submit drug request form and fax supporting documentation to Health New England for review
Health New England does not cover brand-name drugs that have FDA‑approved generic equivalents unless the provider demonstrates medical necessity. Medical necessity may include, but is not limited to, inadequate response or allergic reaction to the generic(s) and failure of alternatives in the drug class. Providers may request coverage by submitting a drug request form and faxing supporting documentation to Health New England for review.
Prior Authorization, Documentation, and Step Requirements
Prior Authorization Required
Prior authorization is required for Brand Non-Formulary drugs and for brand-name drugs when a generic equivalent exists unless medical necessity is documented. To request prior authorization, submit a completed drug request/prior authorization form and supporting clinical documentation to Health New England for review.
- Submit completed PA/drug request form
- Fax supporting clinical documentation to Health New England
- Approval contingent on documentation of medical necessity
Step Therapy Expectation
Health New England expects failure of appropriate alternatives within the same drug class (implicit step therapy) before approving brand-name therapy when generics or formulary alternatives exist. Document trials of and inadequate response to, or intolerance/allergy to, generic(s) or formulary alternatives in the patient record and include this information with the PA request.
- Document trial(s) of generic(s) or formulary alternative(s) with dates and outcomes
- State reason for failure (lack of efficacy), intolerance, or allergy
- Include duration of therapy tried and any objective measures of response
Documentation Required for Brand-Name Override
When requesting a brand-name override (brand preferred over available generic), include complete clinical documentation demonstrating medical necessity. Lack of required documentation may result in denial. Provide copies of office notes, lab results, allergy information, and detailed records of prior medication trials.
- Clinical notes describing rationale for brand over generic
- Documentation of trial(s) of generic equivalent(s): drug name(s), dose, start/stop dates, reason for discontinuation
- Allergy or intolerance documentation if applicable
- Relevant lab or diagnostic results supporting the medical necessity
- Completed PA/drug request form and prescriber signature
Step Therapy Requirements
| Step | Requirement | Failure/Intolerance Criteria | Provider Action |
|---|---|---|---|
| 1 | |||
| Demonstration of failure or intolerance to preferred alternatives prior to coverage of brand-name drugs when FDA-approved generics exist | |||
| Inadequate response or allergic reaction to the generic(s); failure of alternatives in the drug class | |||
| Provider must submit a drug request form and fax supporting documentation to Health New England for prior authorization documenting medical necessity |
Formulary Tier Definitions
Policy Context
The plan uses a three‑tier copay structure: Generic/Tier 1, Brand Formulary/Tier 2, and Brand Non‑Formulary/Tier 3. Generics (Tier 1) are FDA‑approved products with the same active ingredients as brand drugs and are preferred because they are equally safe and effective and generally less expensive. Under Massachusetts law, pharmacists must dispense generics unless the prescriber writes 'no substitution' on the prescription. Brand Non‑Formulary drugs are covered at the highest copay, and brand drugs with FDA‑approved generics require documented medical necessity and prior authorization for coverage.
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