CurrentHealth-New-EnglandPolicy N/A
Pharmacy benefit copay tiers and coverage rules
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Defines 3-tier and 5-tier pharmacy benefit copay structures, mail-order rules, out-of-plan coverage, specialty drug handling, and prior authorization/medical necessity requirements for Health-New-England PPO plans referenced (national, MA). Affects members and prescribing providers under the listed plan options.
Policy Summary
PayerHealth-New-England
PolicyPharmacy benefit copay tiers and coverage rules
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 by submitting a drug request form with documentation of medical necessity (e.g., inadequate response or allergic reaction to generics and failure of alternatives).
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
3copay tiers described (3-tier option)
5copay tiers described (5-tier option)
$10/$35/$60example retail copays (3-tier option, sample)
Mail order limitsmail order copays listed
20%out-of-plan retail coinsurance after copay
Pharmacy Coverage Criteria
Pharmacy coverage criteria
Coverage and payment rules for prescription drugs under the listed pharmacy benefit options:
ALL of the following
- Prescription drugs are subject to the combined medical and pharmacy deductible for this plan.
Copay schedule examples
- 3-tier sample copay examples (retail): $10/$35/$60; $10/$45/$75; $15/$50/$75; $20/$60/$90; $25/$60/$100 (mail order copays shown per schedule).
- 5-tier sample copay examples (retail): $15/$30/$50/$100/$150; $20/$50/$100/$150/$250; $30/$80/$125/$250/20% (mail order copays shown per schedule; mail order not available for Specialty drugs in some 5-tier options).
- For prescriptions from an Out-of-Plan retail pharmacy, 20% coinsurance applies after copay.
- Mail order prescriptions from Out-of-Plan providers are not covered.
- Mail order copays are specified for each copay schedule; mail order is not available for Specialty drugs in some 5-tier options.
- Specialty drugs from Out-of-Plan providers are not covered; specialty drugs may be categorized as Tier 4 (Formulary Specialty) or Tier 5 (Non-Formulary Specialty) with higher copays and potential mail-order limitations.
- Health New England may require prior authorization and documentation of medical necessity to cover brand-name drugs when FDA-approved generic equivalents exist (examples of medical necessity include inadequate response or allergic reaction to generics and failure of alternatives). Providers may request prior authorization by submitting a drug request form and documentation for review.
Definitions: Generic/Tier 1 — FDA-approved generics with same active ingredients as brand drugs; in Massachusetts pharmacists are required to dispense generic unless 'no substitution' is ordered.
Definitions: Brand Formulary/Tier 2 — Brand formulary drugs selected based on safety, effectiveness and cost; copay higher than generic but lower than non-formulary.
Definitions: Brand Non-Formulary/Tier 3 — Brand drugs not selected as formulary; covered at higher copay. Health New England covers brand-name drugs that have FDA-approved generics only if medical necessity is shown and prior authorization is approved.
Definitions: Formulary Specialty/Tier 4 and Non-Formulary Specialty/Tier 5 — Specialty drugs selected by review of safety, effectiveness and cost (Tier 4) or not selected as formulary specialty (Tier 5); these are covered but at higher copays and mail-order may be limited or unavailable.
Copays, Coinsurance, and Coding Examples
3‑Tier Copay Schedule examplesmixed
| $10/$35/$60 | Retail copays: Generic / Brand Formulary / Brand Non‑Formulary |
| Mail: $20/$70/$180 | Mail order copays: Generic / Brand Formulary / Brand Non‑Formulary |
| $10/$45/$75 | Retail copays: Generic / Brand Formulary / Brand Non‑Formulary |
| Mail: $20/$90/$225 | Mail order copays: Generic / Brand Formulary / Brand Non‑Formulary |
| $15/$50/$75 | Retail copays: Generic / Brand Formulary / Brand Non‑Formulary |
| Mail: $30/$100/$225 | Mail order copays: Generic / Brand Formulary / Brand Non‑Formulary |
| $20/$60/$90 | Retail copays: Generic / Brand Formulary / Brand Non‑Formulary |
| Mail: $40/$120/$270 | Mail order copays: Generic / Brand Formulary / Brand Non‑Formulary |
| $25/$60/$100 | Retail copays: Generic / Brand Formulary / Brand Non‑Formulary |
| Mail: $50/$120/$300 | Mail order copays: Generic / Brand Formulary / Brand Non‑Formulary |
5‑Tier Copay Schedule examplesmixed
| $15/$30/$50/$100/$150 | Retail copays: Generic / Brand Formulary / Brand Non‑Formulary / Specialty Formulary / Specialty Non‑Formulary |
| Mail: $30/$60/$150 | Mail order copays: Generic / Brand Formulary / Brand Non‑Formulary (mail order not available for Specialty drugs) |
| $20/$50/$100/$150/$250 | Retail copays: Generic / Brand Formulary / Brand Non‑Formulary / Specialty Formulary / Specialty Non‑Formulary |
| Mail: $40/$100/$300 | Mail order copays: Generic / Brand Formulary / Brand Non‑Formulary (mail order not available for Specialty drugs) |
| $30/$80/$125/$250/20% | Retail copays: Generic / Brand Formulary / Brand Non‑Formulary / Specialty Formulary / Specialty Non‑Formulary (last tier shown as 20%) |
| Mail: $60/$160/$375 | Mail order copays: Generic / Brand Formulary / Brand Non‑Formulary (mail order not available for Specialty drugs) |
Out-of-plan retail coinsurance — 20% after copay
Out-of-plan retail coinsurance20% coinsurance applies after copay for prescriptions from an Out-of-Plan retail pharmacy.
Mail order from out-of-plan providersMail Order prescriptions from Out-of-Plan providers are not covered.
Specialty drugs from out-of-plan providersSpecialty drugs from Out-of-Plan providers are not covered.
Prior Authorization and Provider Requirements
Prior Authorization
Prior authorization required for brand-name drugs when generics exist
Providers may request prior authorization for a brand-name drug by completing and submitting a drug request form to Health New England and including documentation that demonstrates medical necessity (for example: inadequate response or allergic reaction to the generic(s), and failure of alternatives in the drug class).
- Submit a completed drug request form and fax to Health New England for review.
- Include documentation of medical necessity (e.g., inadequate response or allergic reaction to generics; failure of alternatives).
Tier Definitions and Specialty Drug Categories
Generic / Tier 1 — definition and MA pharmacist rule
DefinitionGeneric/Tier 1: FDA-approved generics contain the same active ingredients as brand drugs, are as safe and effective, and usually cost less.
Massachusetts pharmacist ruleIn Massachusetts, pharmacists are required to fill generic drugs unless the prescriber writes 'no substitution' on the prescription to indicate brand only.
Cost positioningGenerics are positioned as the lowest-cost tier compared with Brand Formulary and Brand Non-Formulary tiers.
Brand Formulary / Tier 2 — definition and cost positioning versus generics
DefinitionBrand Formulary/Tier 2: Brand drugs marketed under a trademarked name selected for formulary based on relative safety, effectiveness and cost.
Cost positioningCopay for Brand/Formulary drugs is higher than generics but lower than Brand/Non-Formulary drugs.
Selection basisFormulary selection is based on review of the many FDA-approved drugs on the market for safety, effectiveness and cost.
Brand Non-Formulary / Tier 3 — definition and coverage exceptions
DefinitionBrand Non-Formulary/Tier 3: Brand name drugs not selected as Brand/Formulary; these are covered but at the highest copay level.
Coverage exceptionsHealth New England covers brand-name drugs that have FDA‑approved generic equivalents only if medical necessity is shown and approved.
Prior authorization processA prescriber may request prior authorization by submitting a drug request form with documentation of medical necessity (e.g., inadequate response or allergic reaction to generics and failure of alternatives).
Specialty / Tiers 4-5 — formulary and non-formulary specialty drug descriptions
Formulary Specialty (Tier 4)Formulary Specialty drugs are selected based on relative safety, effectiveness and cost among FDA‑approved specialty products.
Non‑Formulary Specialty (Tier 5)Non‑Formulary Specialty drugs are specialty brand drugs not selected as Tier 4; they are covered but at the highest copay level.
Mail-order and out-of-plan limitsSpecialty drugs often have higher copays and mail order may not be available; Specialty drugs from Out‑of‑Plan providers are not covered.
Policy Summary
PayerHealth-New-England
PolicyPharmacy benefit copay tiers and coverage rules
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 by submitting a drug request form with documentation of medical necessity (e.g., inadequate response or allergic reaction to generics and failure of alternatives).
SourceLink
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