Pharmacy benefit copay tiers and coverage rules for PPO Thrive 3000 National LG (NC)
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Defines 3- and 5-tier pharmacy benefit options, copayment and mail-order rules, deductible and out-of-plan coverage for PPO Thrive 3000 National LG members in North Carolina (NC). Affects members, prescribing providers, and pharmacies.
No material clinical or coverage changes in this revision.
Pharmacy Coverage Rules
Pharmacy coverage criteria
Coverage rules for PPO Thrive 3000 National LG pharmacy options:
ALL of the following
Examples
- 3‑tier example (retail): $10 (Generic) / $50 (Brand Formulary) / $250 (Brand Non‑Formulary); Mail order: $20 / $100 / $750.
- Alternate 3‑tier example (retail): $25 (Generic) / $50 (Brand Formulary) / $150 (Brand Non‑Formulary); Mail order: $50 / $100 / $450.
- 5‑tier example (retail): $25 (Generic) / $50 (Brand Formulary) / $150 (Brand Non‑Formulary) / $250 (Formulary Specialty) / 20% (Non‑Formulary Specialty); Mail order: $50 / $100 / $450.
ALL of the following
ANY of the following
- For 3‑tier options, the plan deductible applies to Brand Formulary and Brand Non‑Formulary drugs.
- For 5‑tier option, the plan deductible applies to Brand Formulary, Brand Non‑Formulary, Formulary Specialty and Non‑Formulary Specialty drugs.
ALL of the following
- For prescriptions from an out‑of‑plan retail pharmacy, 20% coinsurance applies after the copay.
- Mail order prescriptions from out‑of‑plan providers are not covered.
- For the 5‑tier option, specialty drugs from out‑of‑plan providers are not covered.
ALL of the following
- Brand Non‑Formulary drugs with available generics are covered only if medical necessity is shown.
- Providers may request prior authorization and must submit clinical documentation (for example: inadequate response to generics or allergic reaction to generics) using the drug request process outlined by Health New England.
Copay Tiers, Deductible, and Coding Notes
| $10/$50/$250 | Generic / Brand Formulary / Brand Non-Formulary (retail example) |
| $25/$50/$150 | Generic / Brand Formulary / Brand Non-Formulary (retail example) |
| $20/$100/$750 | Generic / Brand Formulary / Brand Non-Formulary (mail order example) |
| $50/$100/$450 | Generic / Brand Formulary / Brand Non-Formulary (mail order example) |
| $25/$50/$150/$250/20% | Tiers 1-5: Generic / Brand Formulary / Brand Non-Formulary / Formulary Specialty / Non-Formulary Specialty (retail example) |
| $50/$100/$450 | Mail order copays corresponding to the 5-tier example |
Provider Requirements and Prior Authorization
Prior Authorization Required for Brand Non-Formulary Drugs
Prior authorization is required for Brand Non-Formulary (Tier 3) drugs when a brand name medication has an FDA‑approved generic equivalent. Providers must submit a drug request form and supporting documentation demonstrating medical necessity for coverage of the Brand Non‑Formulary product.
- Submit completed drug request form to Health New England (fax) for prior authorization review
- Include documentation of medical necessity: e.g., inadequate response to generic(s), allergic reaction to generic(s), or failure of alternatives in the drug class
- Coverage for Brand Non‑Formulary drugs is considered only when a medical necessity justification is provided
- Brand Non‑Formulary drugs remain covered only at the highest copay level if prior authorization is granted
Tier Definitions
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