CurrentHealth-New-EnglandPolicy N/A

HMO Choice Plus LG pharmacy copay tiers

Defines 3-tier and 5-tier pharmacy benefit copay structures and tier definitions for Health New England HMO Choice Plus LG members, including mail order differences and specialty drug notes. Affects members covered under the named plan.

Policy Summary

PayerHealth-New-England

PolicyHMO Choice Plus LG pharmacy copay tiers

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders may request prior authorization for brand-name drugs when medical necessity is demonstrated by submitting a drug request form and faxing supporting documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$10/$50/$1003-tier retail copays option

$20/$100/$3003-tier mail order copays

$15/$50/$100/$150/$2505-tier retail copays

$30/$100/$3005-tier mail order example

Coverage criteria and tier rules

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Tier copay schedules

Covered under a tiered pharmacy benefit; retail and mail-order copays vary by plan option and mail-order availability may differ for specialty drugs.

3-tier and 5-tier copay structures are offered as plan options; specific copay amounts depend on the chosen plan.

3-tier retail copay examples

Option A (retail): Generic / Brand Formulary / Brand Non-Formulary = $10 / $50 / $100
Option B (retail): Generic / Brand Formulary / Brand Non-Formulary = $15 / $30 / $50
Option C (retail): Generic / Brand Formulary / Brand Non-Formulary = $15 / $50 / $100

3-tier mail order copays

Corresponding mail order for Option A = $20 / $100 / $300
Corresponding mail order for Option B = $30 / $60 / $150
Corresponding mail order for Option C = $30 / $100 / $300

5-tier retail copay (example): Generic / Brand Formulary / Brand Non-Formulary / Formulary Specialty / Non-Formulary Specialty = $15 / $50 / $100 / $150 / $250

5-tier mail order copays (example): Mail order copays listed = $30 / $100 / $300; note that mail order amounts correspond to Non-specialty tiers as shown

Specialty and mail order

Specialty drugs have separate handling and mail-order availability is restricted for specialty products.

Formulary and non‑formulary specialty tiers exist in the 5‑tier structure (Tier 4 = Formulary Specialty; Tier 5 = Non‑Formulary Specialty).

Mail order is not available for Specialty drugs (mail order restriction applies to specialty tiers).

Operational: Specialty drugs remain covered under their respective specialty tiers at the stated retail copay levels; consult specialty tier definitions for coverage details.

Brand-with-generic coverage criteria

Brand-name drugs that have FDA-approved generic equivalents are subject to coverage only when medical necessity is demonstrated.

Health New England covers brand‑name drugs that have FDA‑approved generic equivalents only if medical necessity has been shown.

Examples of medical necessity

Inadequate response to the generic(s)
Allergic reaction to the generic(s)
Failure of alternatives in the drug class

Provider process: Physician may request prior authorization for a brand‑name drug by completing a drug request form and faxing supporting documentation to Health New England for review.

Copay schedules and mail-order notes

3-tier retail copays (option 1)mixed

Retail	$10 / $50 / $100 (Generic / Brand Formulary / Brand Non-Formulary)
Mail Order	$20 / $100 / $300 (Generic / Brand Formulary / Brand Non-Formulary)

3-tier retail copays (option 2)mixed

Retail	$15 / $30 / $50 (Generic / Brand Formulary / Brand Non-Formulary)
Mail Order	$30 / $60 / $150 (Generic / Brand Formulary / Brand Non-Formulary)

3-tier retail copays (option 3)mixed

Retail	$15 / $50 / $100 (Generic / Brand Formulary / Brand Non-Formulary)
Mail Order	$30 / $100 / $300 (Generic / Brand Formulary / Brand Non-Formulary)

5-tier retail copaysmixed

Retail	$15 / $50 / $100 / $150 / $250 (Generic / Brand Formulary / Brand Non-Formulary / Formulary Specialty / Non-Formulary Specialty)
Mail Order	$30 / $100 / $300 (Generic / Brand Formulary / Brand Non-Formulary) — Mail order is not available for Specialty drugs

Mail order specialty availability

Mail order availabilityMail order is not available for Specialty drugs.

Applicable plan5‑Tier 2024 Pharmacy Benefit Option for HMO Choice Plus LG

Mail order copay exampleMail order copays listed for non‑specialty tiers: $30/$100/$300 (Generic / Brand Formulary / Brand Non‑Formulary)

Provider requirements and prior authorization

Prior Authorization

Prior authorization required for Brand Non‑Formulary when medical necessity shown

Prior authorization may be required for brand-name drugs that have FDA‑approved generic equivalents. To request review, the physician must complete a drug request form and fax it to Health New England with documentation demonstrating medical necessity (examples include inadequate response or allergic reaction to the generic(s) or failure of alternatives in the drug class).

Complete and submit the drug request form.
Fax supporting documentation showing medical necessity (e.g., inadequate response, allergy to generic, failure of alternatives).

Tier definitions

Generic / Tier 1

DefinitionGeneric/Tier 1: FDA‑approved generics containing the same active ingredients as the brand; as safe and effective and usually lower cost.

Pharmacist substitution noteIn Massachusetts, pharmacists are required to fill generics unless the prescriber indicates 'no substitution' on the prescription.

Cost positioningCopay for generic drugs is lower than Brand/Formulary and Brand/Non‑Formulary tiers.

Brand Formulary / Tier 2

DefinitionBrand Formulary/Tier 2: Trademarked brand drugs without less expensive generic equivalents, selected for the formulary based on relative safety, effectiveness, and cost.

Formulary selection rationaleDrugs are selected after review of safety, effectiveness and cost among FDA‑approved options.

Cost positioningCopay for Brand/Formulary drugs is higher than generic but lower than Brand/Non‑Formulary.

Brand Non-Formulary / Tier 3

DefinitionBrand Non‑Formulary/Tier 3: Any brand name drug not selected as a Brand/Formulary drug by Health New England.

Coverage notesThese drugs are still covered but at a higher or highest copay level; brand drugs with FDA‑approved generics are covered only if medical necessity is shown.

Prior authorization processPhysician may request prior authorization by completing a drug request form and faxing supporting documentation of medical necessity (e.g., inadequate response or allergic reaction to generics, failure of alternatives).

Formulary Specialty / Tier 4

DefinitionFormulary Specialty/Tier 4: Specialty drugs selected for the formulary based on a review of relative safety, effectiveness, and cost among FDA‑approved drugs.

Selection basisIncluded after evaluation of clinical and cost factors compared to other specialty options.

Coverage implicationFormulary specialty drugs are covered under the specialty tier (Tier 4) with associated copay; mail order availability may differ (see mail order rules).

Non-Formulary Specialty / Tier 5

DefinitionNon‑Formulary Specialty/Tier 5: Any brand name specialty drug not selected as a Formulary Specialty Drug by Health New England; includes brand drugs that have formulary generic and brand alternatives.

Coverage implicationsThese medications are still covered but at the highest copay level for specialty drugs; mail order is not available for specialty drugs.

Positioning vs. formulary specialtyTier 5 applies when Health New England has not selected the drug for Tier 4 and indicates higher member cost responsibility.