CurrentHealth-New-EnglandPolicy N/A

Pharmacy benefit copay tiers and coverage criteria

Defines 3-tier and 5-tier pharmacy benefit copay structures and tier definitions for HMO Choice Plus LG members under Health New England; affects members in Massachusetts (note about MA generic substitution).

Policy Summary

PayerHealth-New-England

PolicyPharmacy benefit copay tiers and coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider may request prior authorization for a brand name drug by submitting a drug request form and faxing documentation of medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$10/$50/$1003-tier in-person

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

$15/$50/$100/$150/$2505-tier in-person

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

Not availablespecialty mail-order

Pharmacy Tier Coverage Criteria

Pharmacy tier coverage criteria

Drugs are covered according to tier definitions and copay schedules; exceptions for brand drugs when FDA‑approved generics exist require documentation of medical necessity.

Coverage is determined by the pharmacy benefit tier definitions and associated copay schedules (3‑tier or 5‑tier options).

Tier 1 — Generic: Generic/Tier 1: FDA‑approved generics with the same active ingredients as brand products; generally lowest copay. In Massachusetts pharmacists are required to dispense the generic unless the prescriber writes 'no substitution' on the prescription.

Tier 2 — Brand Formulary: Brand Formulary/Tier 2: Trademarked brand drugs selected for the formulary based on safety, effectiveness and cost; covered with a higher copay than generics but lower than non‑formulary brands.

Tier 3 — Brand Non‑Formulary:

Policy Summary

PayerHealth-New-England

PolicyPharmacy benefit copay tiers and coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider may request prior authorization for a brand name drug by submitting a drug request form and faxing documentation of medical necessity.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Copay Schedules & Medical Necessity

3-tier in-person copays (examples)mixed

$10/$50/$100	Generic / Brand Formulary / Brand Non-Formulary (in-person)
$15/$30/$50	Alternate example Generic / Brand Formulary / Brand Non-Formulary (in-person)
$15/$50/$100	Alternate example Generic / Brand Formulary / Brand Non-Formulary (in-person)

3-tier mail-order copays (examples)mixed

$20/$100/$300	Mail Order Generic / Brand Formulary / Brand Non-Formulary (corresponding to $10/$50/$100 plan)
$30/$60/$150	Mail Order Generic / Brand Formulary / Brand Non-Formulary (corresponding to $15/$30/$50 plan)
$30/$100/$300	Mail Order Generic / Brand Formulary / Brand Non-Formulary (corresponding to $15/$50/$100 plan)

5-tier in-person copay (example)mixed

$15/$50/$100/$150/$250

Generic / Brand Formulary / Brand Non-Formulary / Formulary Specialty / Non-Formulary Specialty (in-person)

5-tier mail-order copays (example; specialty limitation)mixed

$30/$100/$300

Mail Order Generic / Brand Formulary / Brand Non-Formulary. Note: Mail order is not available for Specialty drugs.

Medical necessity for brand when generic exists

Required documentationMedical necessity must be shown for brand name drugs that have FDA‑approved generic equivalents; examples include inadequate response or allergic reaction to the generic(s) and failure of alternatives in the drug class.

Provider action to request coverageDoctor may request prior authorization by filling out a drug request form and faxing documentation of medical necessity to Health New England.

ScopeApplies when a brand name drug has an FDA‑approved generic equivalent and is otherwise a Brand/Non‑Formulary (Tier 3) or Non‑Formulary Specialty (Tier 5) medication.

Prior Authorization & Provider Requirements

Prior Authorization

Prior authorization required for brand when generics available; submit drug request form and medical necessity

Your office may request prior authorization for a brand-name drug that has an FDA‑approved generic equivalent by completing a drug request form and faxing it to Health New England along with documentation of medical necessity. Medical necessity examples include inadequate response or allergic reaction to the generic(s) and failure of alternatives in the drug class.

Submit a completed drug request form to Health New England.
Fax supporting documentation that demonstrates medical necessity (e.g., inadequate response or allergic reaction to generics; failure of alternatives in the drug class).

Tier Definitions

Generic / Tier 1

DefinitionGeneric/Tier 1: FDA‑approved generic drugs containing the same active ingredients as brand products; as safe and effective and usually cost less.

Massachusetts substitution noteIn Massachusetts, pharmacists are required to fill generic drugs unless the prescriber writes 'no substitution' on the prescription.

Coverage roleTier 1 drugs receive standard coverage and the lowest copay within the benefit design.

Brand Formulary / Tier 2

DefinitionBrand Formulary/Tier 2: Trademarked brand drugs selected for the formulary based on relative safety, effectiveness and cost; have no less expensive generic equivalents.

Cost placementCopay for Brand/Formulary drugs is higher than generics but lower than Brand/Non‑Formulary drugs.

Selection criteriaDrugs are chosen for formulary status after review of the many FDA‑approved drugs on the market for safety, effectiveness and cost.

Brand Non‑Formulary / Tier 3

DefinitionBrand Non‑Formulary/Tier 3: Any brand name drug not selected as Brand/Formulary; still covered but at a higher or highest copay level depending on benefit structure.

Coverage and requirementsCovered at the highest copay level for non‑specialty structure; Health New England covers brand name drugs with FDA‑approved generics only if medical necessity is shown.

Provider actionProviders may request prior authorization with supporting documentation of medical necessity (e.g., inadequate response/allergy/failure of alternatives).

Formulary Specialty / Tier 4

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

Coverage levelCovered as formulary specialty medications under the specialty tier (Tier 4) with applicable specialty copays.

Selection criteriaInclusion is based on evaluation of safety, effectiveness and cost of available FDA‑approved drugs in the specialty class.

Non‑Formulary Specialty / Tier 5

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

Cost and coverage guidanceThese medications are still covered but at the highest copay level; mail order is not available for specialty drugs.

Formulary relationshipTier 5 includes specialty drugs that were not selected as Tier 4 formulary specialty options and may have formulary alternatives.