CurrentHealth-New-EnglandPolicy N/A

Pharmacy benefit tiers and copay structure (coverage criteria)

Defines Health New England's pharmacy benefit tier definitions and member copay amounts for multiple plan options; affects members using prescription drugs and providers prescribing medications within the Health New England HMO plans.

Policy Summary

PayerHealth-New-England

PolicyPharmacy benefit tiers and copay structure (coverage criteria)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a drug request form with documentation showing medical necessity when requesting a brand drug with an available generic.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

33-tier option

55-tier option

$10/$45/$75Example copay

ExcludedMail-order specialty

Coverage rules and criteria

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Medical necessity for brand with generic

Reasons supporting medical necessity: At least one of the following: inadequate response to the generic(s); allergic reaction to the generic(s); failure of alternatives in the drug class.
Examples provided in policy text
Prior authorization submission: Provider submits a drug request form and supporting documentation (e.g., clinical rationale, prior trial documentation) to Health New England for review and approval prior to coverage of the brand product.
Form must be completed and faxed per policy

Step therapy expectation: Evidence that alternatives in the drug class were tried and failed is expected as part of medical necessity before a higher-tier brand is covered.

Implicit step requirement per policy; documents trial/failure of alternatives

Provider requirements and prior authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for coverage of brand name drugs when an FDA-approved generic equivalent exists and medical necessity is claimed. To request prior authorization, the provider must submit a completed drug request/prior authorization form to Health New England for review.

Submit the drug request form and supporting medical documentation via fax to Health New England (use the payer-specific fax on the form).
Include clinical rationale and records demonstrating why the generic is unsuitable.
Requests without required documentation may be delayed or denied.

Step Therapy

Medical Necessity — Step Therapy Requirement

Medical necessity for coverage of a brand name drug in the presence of an FDA-approved generic requires documentation that the member has had an inadequate response, intolerance, or allergic reaction to the generic(s), and evidence of failure of reasonable alternatives within the drug class. This implicit step requirement (step therapy) must be addressed in the submission.

Document trial(s) of the generic alternative(s), including dose, duration, and reason for discontinuation (e.g., lack of efficacy, adverse reaction).
If step therapy cannot be followed for clinical reasons, provide supporting clinical justification and relevant medical records.

Documentation Required

Documentation Required for Prior Authorization

Documentation must accompany all prior authorization requests to support the claim of medical necessity. Incomplete documentation may result in denial or request for additional information.

Completed drug request/prior authorization form.
Clinical notes, prior medication history, lab results or diagnostic testing that support the need for the brand product.
Specifically state prior trials of generics and reasons they were ineffective or not tolerated.

Denial Risk

Denial Risk if Medical Necessity Not Shown

Coverage of the brand name drug is conditional on demonstration of medical necessity. Failure to provide adequate documentation that meets the medical necessity and step-therapy requirements may result in denial of coverage.

If medical necessity is not demonstrated, the prior authorization will be denied and the member may be responsible for the cost.
Providers may appeal denials per Health New England's appeal process; include any additional supporting documentation with the appeal.

Pharmacy 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 as brand products; usually lower cost.

Massachusetts dispensing notePharmacists in Massachusetts are required to dispense a generic unless the prescriber writes 'no substitution' on the prescription.

Cost implicationTypically the lowest copay level in the pharmacy benefit (base tier in 3- and 5-tier designs).

Brand Formulary / Tier 2

DefinitionBrand Formulary/Tier 2: Brand drugs marketed under a trademarked name with no less expensive generic equivalents; selected for the formulary based on relative safety, effectiveness, and cost.

Copay relationCopay for Brand/Formulary drugs is higher than generic but lower than Brand/Non-Formulary drugs.

Selection basisIncluded on the formulary after review of FDA‑approved options for safety, effectiveness and cost.

Brand Non-Formulary / Tier 3

DefinitionBrand Non-Formulary/Tier 3: Brand name drugs not selected as Brand/Formulary; covered but at a higher (or highest for some plans) copay level.

Coverage conditionHealth New England covers brand name drugs that have FDA‑approved generic equivalents only if medical necessity is shown; prior authorization may be required.

Copay policyThese drugs are covered at the highest copay level in standard tier structures; Health New England does not waive or reduce copays for Brand/Non‑Formulary drugs.

Formulary Specialty / Tier 4

DefinitionFormulary Specialty/Tier 4: Specialty drugs selected for the formulary specialty category based on review of relative safety, effectiveness, and cost.

Category purposeRepresents specialty medications chosen for coverage within the specialty tier after clinical and cost review.

Copay implicationTypically a specialty copay level (tiered above traditional brand tiers).

Non-Formulary Specialty / Tier 5

DefinitionNon-Formulary Specialty/Tier 5: Specialty drugs not selected as Formulary Specialty; includes brand drugs that have formulary generic and brand alternatives.

Coverage and copayThese medications are still covered but at the highest specialty copay level.

Relationship to alternativesCategory includes specialty brand drugs where formulary alternatives exist but the drug itself was not selected for Formulary Specialty status.

Step	Requirement	Evidence needed	Coverage label
1	Brand drug with an FDA‑approved generic exists	Documentation of medical necessity demonstrating one or more of: inadequate response to the generic(s); allergic reaction to the generic(s); failure of alternatives in the drug class.	Requires prior authorization and medical necessity review

Background and rationale

Generic drugs contain the same active ingredients as brand drugs and are considered safe and effective when approved by the FDA. The plan distinguishes drug tiers (for example, Generic / Tier 1, Brand Formulary / Tier 2, and Brand Non‑Formulary / Tier 3 in a 3‑tier model, with additional specialty tiers in a 5‑tier model) to manage cost and utilization. Copay examples illustrate relative member cost sharing (for instance, a sample 5‑tier schedule shows $20/$50/$100/$150/$250 and corresponding mail‑order values where applicable). Where a generic equivalent exists, coverage of the brand is conditioned on demonstration of medical necessity and may require prior authorization and documentation of trial/failure or intolerance to the generic alternatives.

OpenPayer

Pharmacy benefit tiers and copay structure (coverage criteria)

Coverage rules and criteria

Provider requirements and prior authorization

Pharmacy tier definitions

Step therapy / treatment trial expectations

Site of care and dispensing

Background and rationale