CurrentHealth-New-EnglandPolicy N/A

2025 Pharmacy Benefit Options for HMO Essential 5000 LG

Defines 2025 pharmacy benefit options (3-tier and 5-tier) for Health New England HMO Essential 5000 LG plans, including copay amounts, mail-order rules, and tier definitions for members in Massachusetts.

Policy Summary

PayerHealth-New-England

Policy2025 Pharmacy Benefit Options for HMO Essential 5000 LG

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review Date

Key ActionSubmit a drug request form and fax it with documentation of medical necessity to request prior authorization for brand-name drugs when generics are inadequate or cause adverse reactions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3-tierbenefit option described

5-tierbenefit option described

$15/$50/$75example 3-tier copay (in-network)

$30/$60/$150example 5-tier mail-order copays (one option)

No specialty mailmail-order restriction

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Tiered Pharmacy Coverage

Tiered coverage criteria

Covered according to the member’s selected pharmacy benefit option; copays and mail‑order rules vary by 3‑tier or 5‑tier plan selection.

Coverage is tier‑based; members are assigned benefits under either a 3‑tier or 5‑tier pharmacy plan option, and copays depend on the selected option.

3‑Tier plan options

Example in‑network retail copays: $15 (Tier 1 Generic) / $50 (Tier 2 Brand Formulary) / $75 (Tier 3 Brand Non‑Formulary).example amounts
See plan materials for exact copays that apply to the member's selected option.
Corresponding mail‑order copays for listed 3‑tier examples include: $30 (Generic) / $100 (Brand Formulary) / $225 (Brand Non‑Formulary); other 3‑tier mail‑order schedules may apply (e.g., $50/$100/$300).
Mail‑order copays vary by specific 3‑tier option.

5‑Tier plan options

Example in‑network retail copays: $15 (Tier 1 Generic) / $30 (Tier 2 Brand Formulary) / $50 (Tier 3 Brand Non‑Formulary) / $100 (Tier 4 Formulary Specialty) / $150 (Tier 5 Non‑Formulary Specialty).example amounts
Multiple 5‑tier schedules are described; exact copays depend on the selected 5‑tier option.
Corresponding mail‑order copays for listed 5‑tier examples include: $30 (Generic) / $60 (Brand Formulary) / $150 (Brand Non‑Formulary).
Mail order is not available for Specialty drugs.
Other 5‑tier copay schedules (examples) include: $15/$50/$100/$150/$250 with mail‑order $30/$100/$300; $25/$50/$150/$250/20% with mail‑order $50/$100/$450; and others described in plan materials.
See plan materials for the full list of 5‑tier options.

ALL of the following

Specialty drugs (Formulary Specialty/Tier 4 and Non‑Formulary Specialty/Tier 5) are assigned to specialty tiers and are subject to specialty copays.
Mail order is not available for specialty drugs; specialty medications must be filled through approved specialty channels or as directed by the plan.

ALL of the following

Brand Non‑Formulary (Tier 3 in 3‑tier; Tier 3 in 5‑tier) and Non‑Formulary Specialty drugs may require documentation of medical necessity for coverage when an FDA‑approved generic or formulary alternative exists.
Medical necessity examples include inadequate response or allergic reaction to the generic(s) and failure of alternatives in the drug class; providers should submit a drug request form and fax supporting documentation to Health New England for review.

ALL of the following

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

Prior Authorization and Provider Requirements

Prior Authorization

Prior Authorization Required for Brand/Non-Formulary Drugs

Prior authorization is required for Brand/Non-Formulary (Tier 3) drugs when a covered FDA-approved generic equivalent exists unless Medical Necessity is demonstrated. To request prior authorization, the prescribing provider must complete and submit a Health New England drug request/prior authorization form and include supporting documentation demonstrating medical necessity (examples below). Health New England will review the request and notify the provider of the determination. Failure to obtain prior authorization when required may result in claim denial or member financial responsibility for the drug.

Affected drugs: Brand Non-Formulary / Tier 3 products (brand-name drugs with available FDA-approved generics).
Submit: completed drug request / prior authorization form to Health New England (fax or electronic portal per payer instructions).
Documentation: clinical notes, prior treatment history, allergy documentation, lab results, and any relevant consultation notes.
Examples of acceptable medical necessity documentation: inadequate response to two formulary generics or intolerable adverse reaction/allergy to generics; contraindication to all available generics; documented therapeutic failure of alternatives in the drug class.
If prior authorization is approved: include authorization number and approved duration on the claim.
If denied: appeal and medical records submission instructions available from Health New England.

Tier Definitions

Tier definitions (3-tier)

Tier definitions (5-tier)