Prescription drug copay tiers and mail order copays
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Defines retail and mail-order copay amounts and explains the three copay tiers (Generic, Brand Formulary, Brand Non-Formulary) including prior authorization for brand-name drugs with generic equivalents. Applies to Health New England members to whom these benefit rules are offered.
No material clinical or coverage changes in this revision.
Coverage Criteria
Brand-name with generic equivalent
Covered when ALL of the following are met:
ALL of the following
- Brand-name drugs that have FDA‑approved generic equivalents are covered only when medical necessity is demonstrated.
Medical necessity may be demonstrated by one of the following:
- Inadequate response to the generic(s).
- Allergic reaction to the generic(s).
- Failure of alternatives in the same drug class.
- Provider submits a completed drug request form and faxes it to Health New England with supporting documentation to request prior authorization.
Copays and Medical Necessity Examples
| Generic | $10 |
| Brand Formulary | $25 |
| Brand Non-Formulary | $50 |
| Generic | $20 |
| Brand Formulary | $50 |
| Brand Non-Formulary | $150 |
Provider Actions and Requirements
Prior authorization required for brand-name drugs with FDA-approved generics
Prior authorization may be requested for a brand name drug that has an FDA‑approved generic equivalent when medical necessity is demonstrated (for example, inadequate response or allergic reaction to the generic(s), or failure of alternatives in the drug class). Providers must complete a drug request form and fax it to Health New England with documentation of medical necessity for review.
- Complete and sign the drug request form.
- Fax the completed form and supporting documentation of medical necessity to Health New England for review.
- Document examples of medical necessity: inadequate response to generics, allergic reaction to generics, or failure of alternatives in the drug class.
Tier Definitions
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