Prescription drug copayment tiers and prior authorization for brand-name drugs
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This document defines retail and mail-order copay amounts by drug tier and explains tier definitions, coverage stance for brand drugs with generic equivalents, and the prior authorization requirement for medical necessity. It applies to Health New England members (Massachusetts referenced).
No material clinical or coverage changes in this revision.
Coverage rules and exceptions
Brand-name coverage with generic equivalents
Covered only when ALL of the following are met:
Medical necessity may be demonstrated by
- Inadequate response to the generic(s).
- Allerg ic reaction to the generic(s).
- Failure of alternatives in the drug class.
Copay tiers and coding
| Generic / Tier 1 | $10 (retail) |
| Brand Formulary / Tier 2 | $25 (retail) |
| Brand Non-Formulary / Tier 3 | $50 (retail) |
| Generic / Tier 1 | $20 (mail order) |
| Brand Formulary / Tier 2 | $50 (mail order) |
| Brand Non-Formulary / Tier 3 | $150 (mail order) |
Provider requirements and prior authorization
Prior Authorization Required for Brand Non‑Formulary with Generics
Prior authorization is required for Brand Non‑Formulary (Tier 3) drugs when an FDA‑approved generic equivalent exists. Health New England covers Brand Non‑Formulary drugs with a generic equivalent only when medical necessity is demonstrated.
- Affected category: Brand Non‑Formulary / Tier 3 drugs with available FDA‑approved generic equivalents
- Required documentation: clinical rationale demonstrating medical necessity (for example, inadequate response or allergic reaction to the generic(s), or failure of alternatives in the drug class)
- How to request: prescriber must complete and fax a drug request/prior authorization form to Health New England for review
- Consequences of omission: without prior authorization and adequate documentation, the brand drug may be subject to higher copay and may be denied coverage
Tier definitions
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