CurrentHealth-New-EnglandPolicy N/A
2025 Pharmacy Benefit Options and Coverage Rules (PPO Wise 3000/10% National HDHP LG)
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Defines 2025 pharmacy benefit options (3-tier and 5-tier) for PPO Wise 3000/10% National HDHP LG members and rules for retail/mail-order and out-of-plan prescriptions; affects members enrolled in these plans.
Policy Summary
PayerHealth-New-England
Policy2025 Pharmacy Benefit Options and Coverage Rules (PPO Wise 3000/10% National HDHP LG)
Policy CodePolicy N/A
Change TypeNo material change
Effective DateJan 1, 2025
Next Review DateN/A
Key ActionProviders may request prior authorization for a brand-name drug with an FDA-approved generic by submitting a drug request form and faxing medical necessity documentation to Health New England.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
3-tier & 5-tierpharmacy benefit structures described
$10/$45/$75sample in‑network retail copay levels
$375highest mail-order copay listed
20%out-of-plan retail coinsurance
Not coveredout-of-plan mail/specialty
Pharmacy Coverage Criteria and Rules
Pharmacy coverage criteria and rules
Covered when the following plan-level rules and exceptions are met:
ALL of the following
- Combined medical/pharmacy deductible applies to prescription drugs
- For prescriptions from an out-of-plan retail pharmacy, 20% coinsurance applies after the applicable copay
ALL of the following
- Mail-order is covered for in-network pharmacies according to plan copay schedules
- Mail-order prescriptions from out-of-plan providers are not covered
ALL of the following
- Specialty drugs obtained from out-of-plan providers are not covered
- Mail-order is not available for Specialty drugs for certain 5-tier plan options
ALL of the following
- When an FDA‑approved generic equivalent exists, the generic is preferred and pharmacists in Massachusetts must substitute generics unless prescriber indicates 'no substitution'
- Brand name drugs with FDA‑approved generic equivalents are covered only when medical necessity is shown via prior authorization
- Providers may request prior authorization by completing and faxing a drug request form with documentation of medical necessity (examples: inadequate response or allergic reaction to generics, failure of alternatives)
ALL of the following
- 3‑tier and 5‑tier copay schedules are defined by plan option (examples listed in benefit schedules)
- Examples of 3‑tier schedules include $10/$45/$75 (mail order generic/brand/formulary/brand non‑formulary = $20/$90/$225), $15/$30/$50 (mail order = $30/$60/$150), $15/$50/$100 (mail order = $30/$100/$300), $20/$40/$70 (mail order = $40/$80/$210), and $20/$50/$100 (mail order = $40/$100/$300)
- Examples of 5‑tier schedules include $15/$30/$50/$100/$150 (mail order generic/brand formulary/brand non‑formulary = $30/$60/$150), $20/$50/$100/$150/$250 (mail order = $40/$100/$300), and $30/$80/$125/$250/20% (mail order = $60/$160/$375)
ALL of the following
- In Massachusetts, pharmacists are required to fill generic drugs unless the prescriber writes 'no substitution' on the prescription
ALL of the following
- Health New England does not waive or reduce copays for Brand/Non‑Formulary drugs (Tier 3) in 5‑tier plans
Copay Schedules and Cost-Sharing
3-Tier Copay Schedules (examples)mixed
| $10/$45/$75 | In-network retail copay levels: Generic / Brand Formulary / Brand Non-Formulary |
| $15/$30/$50 | In-network retail copay levels: Generic / Brand Formulary / Brand Non-Formulary |
| $15/$50/$100 | In-network retail copay levels: Generic / Brand Formulary / Brand Non-Formulary |
| $20/$40/$70 | In-network retail copay levels: Generic / Brand Formulary / Brand Non-Formulary |
| $20/$50/$100 | In-network retail copay levels: Generic / Brand Formulary / Brand Non-Formulary |
3-Tier Mail Order Copays (examples)mixed
| $20/$90/$225 | Mail order copays corresponding to $10/$45/$75 retail schedule: Generic / Brand Formulary / Brand Non-Formulary |
| $30/$60/$150 | Mail order copays corresponding to $15/$30/$50 retail schedule: Generic / Brand Formulary / Brand Non-Formulary |
| $30/$100/$300 | Mail order copays corresponding to $15/$50/$100 retail schedule: Generic / Brand Formulary / Brand Non-Formulary |
| $40/$80/$210 | Mail order copays corresponding to $20/$40/$70 retail schedule: Generic / Brand Formulary / Brand Non-Formulary |
| $40/$100/$300 | Mail order copays corresponding to $20/$50/$100 retail schedule: Generic / Brand Formulary / Brand Non-Formulary |
5-Tier Copay Schedules (examples)mixed
| $15/$30/$50/$100/$150 | In-network retail copay levels: Generic / Brand Formulary / Brand Non-Formulary / Specialty Formulary / Specialty Non-Formulary |
| $20/$50/$100/$150/$250 | In-network retail copay levels: Generic / Brand Formulary / Brand Non-Formulary / Specialty Formulary / Specialty Non-Formulary |
| $30/$80/$125/$250/20% | In-network retail copay levels: Generic / Brand Formulary / Brand Non-Formulary / Specialty Formulary / Specialty Non-Formulary (last level shown as 20% coinsurance) |
5-Tier Mail Order Copays (examples)mixed
| $30/$60/$150 | Mail order copays corresponding to $15/$30/$50/$100/$150 retail schedule (mail order not available for Specialty drugs) |
| $40/$100/$300 | Mail order copays corresponding to $20/$50/$100/$150/$250 retail schedule (mail order not available for Specialty drugs) |
| $60/$160/$375 | Mail order copays corresponding to $30/$80/$125/$250/20% retail schedule (mail order not available for Specialty drugs) |
Out-of-plan retail coinsurance
Out-of-plan retail coinsurance20% coinsurance applies after the applicable copay for prescriptions dispensed at out-of-plan retail pharmacies.
Out-of-plan mail orderMail order prescriptions from out-of-plan providers are not covered.
Specialty from out-of-planSpecialty drugs from out-of-plan providers are not covered.
Prior Authorization and Provider Steps
Prior Authorization
Prior Authorization Required for Brand-Name Drugs When Generics Exist
Prior authorization is required for brand-name drugs when an FDA‑approved generic equivalent exists. The provider must complete the Health New England drug request form and fax it along with supporting documentation demonstrating medical necessity. Medical necessity may include, but is not limited to: inadequate response to the generic, documented allergy/intolerance to the generic, or failure of other alternatives in the drug class. Include relevant clinical notes, prior treatment history, and any lab results when available to expedite review.
- Complete and sign the Health New England drug request form.
- Fax the completed form and supporting documentation to Health New England for review.
- Medical necessity examples: inadequate response to generic, allergic reaction to generic, failure of alternatives in class.
Tier Definitions (Generic, Brand, Specialty)
Generic / Tier 1
DefinitionGeneric/Tier 1: FDA-approved generics with the same active ingredients as brand-name drugs; safe, effective, and usually lower cost.
Pharmacist substitution rule (MA)In Massachusetts, pharmacists are required to fill generics unless the prescriber writes 'no substitution' on the prescription.
Coverage when brand availableBrand-name drugs that have FDA-approved generic equivalents are covered only when medical necessity is shown (prior authorization may be required).
Brand Formulary / Tier 2
DefinitionBrand Formulary/Tier 2: Brand drugs marketed under a trademarked name that do not have less expensive generic equivalents and are selected for the formulary after review of safety, effectiveness and cost.
Copay positionCopay for Brand/Formulary drugs is higher than generic copays but lower than Brand/Non-Formulary copays.
Selection rationaleDrugs are selected for the formulary based on a comparative review of relative safety, effectiveness, and cost among FDA-approved drugs.
Brand Non-Formulary / Tier 3
DefinitionBrand Non-Formulary/Tier 3: Brand-name drugs not selected as Brand/Formulary; covered but at the highest non-specialty copay level.
Coverage when generics existHealth New England covers brand-name drugs that have FDA-approved generic equivalents only if medical necessity is demonstrated; prior authorization can be requested by the provider with documentation (e.g., inadequate response or allergic reaction to generics).
Copay policyHealth New England does not waive or reduce copays for Brand/Non-Formulary drugs (5-tier statement applies).
Formulary Specialty / Tier 4
DefinitionFormulary Specialty/Tier 4: Specialty drugs that Health New England has selected for the formulary following review of safety, effectiveness and cost.
Coverage implicationsFormulary specialty drugs are covered under the specialty tier and generally subject to specialty copays/requirements as defined by the plan.
Selection processTier 4 designation is based on a comparative review of FDA‑approved specialty medications for safety, effectiveness and cost.
Non-Formulary Specialty / Tier 5
DefinitionNon-Formulary Specialty/Tier 5: Brand specialty drugs that Health New England has not selected as Formulary Specialty; includes brand drugs with formulary generic and brand alternatives.
Cost implicationsThese medications are still covered but at the highest copay level (highest specialty copay).
Formulary alternativesCategory includes specialty brand drugs for which formulary generic or brand alternatives exist but were not selected as Tier 4.
Policy Summary
PayerHealth-New-England
Policy2025 Pharmacy Benefit Options and Coverage Rules (PPO Wise 3000/10% National HDHP LG)
Policy CodePolicy N/A
Change TypeNo material change
Effective DateJan 1, 2025
Next Review DateN/A
Key ActionProviders may request prior authorization for a brand-name drug with an FDA-approved generic by submitting a drug request form and faxing medical necessity documentation to Health New England.
SourceLink
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