CurrentHealth-New-EnglandPolicy N/A
Pharmacy benefit copay tiers and coverage criteria
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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: Brand Non‑Formulary/Tier 3: Brand name drugs not selected as Brand/Formulary; covered at the highest copay for non‑specialty drugs. Brand name drugs that have FDA‑approved generic equivalents are only covered when medical necessity is shown.
Tier 4 — Formulary Specialty: Formulary Specialty/Tier 4: Selected specialty drugs chosen based on review of safety, effectiveness and cost; covered as formulary specialty. Note: mail order may not be available for specialty drugs.
Tier 5 — Non‑Formulary Specialty: Non‑Formulary Specialty/Tier 5: Specialty drugs not selected as formulary specialty; covered at the highest copay level and mail order is not available for specialty drugs. This category may include brand drugs that have formulary generic and brand alternatives.
Medical necessity for brand when generic exists
- Provider must document medical necessity, which may include inadequate response to the generic(s), allergic reaction to the generic(s), or failure of alternatives within the drug class.
- Provider may request prior authorization by submitting a drug request form and faxing documentation of medical necessity to Health New England for review.
Copay schedules and examples: Copay amounts vary by selected benefit option (examples): 3‑tier plans (examples) $10/$50/$100 in‑person with mail order corresponding amounts such as $20/$100/$300; 5‑tier example $15/$50/$100/$150/$250 with mail order examples and note that mail order is not available for Specialty drugs.
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.
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
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