CurrentHealth-New-EnglandPolicy N/A

Pharmacy benefit copay tiers and coverage rules

Defines 3-tier and 5-tier pharmacy benefit options, associated retail and mail-order copays, and rules for out-of-plan pharmacies and specialty drug coverage for Health New England PPO Wise Plus 3000 National HDHP plans.

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 Date

Key ActionSubmit a drug request form with documentation and fax it to Health New England to request prior authorization for a brand-name drug when medical necessity is documented.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

33-tier described

55-tier described

$10/$45/$75example retail copays

Not availablemail-order specialty

20%out-of-plan coinsurance

Pharmacy Coverage and Payment Rules

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 Date

Key ActionSubmit a drug request form with documentation and fax it to Health New England to request prior authorization for a brand-name drug when medical necessity is documented.

SourceLink

On This Page

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Pharmacy coverage and payment rules

Coverage stance and payment rules for pharmacy benefits under the plan options:

Pharmacy benefit structure and copays apply as described for each plan option; prescription drugs are subject to the combined medical/pharmacy deductible for these plans.

3-tier or 5-tier plan options

3-tier option
- Retail copays (Generic / Brand Formulary / Brand Non‑Formulary) examples include: $10/$45/$75; $15/$30/$50; $15/$50/$100; $20/$40/$70; $20/$50/$100.
- Corresponding mail‑order copays for those 3‑tier examples include: $20/$90/$225; $30/$60/$150; $30/$100/$300; $40/$80/$210; $40/$100/$300.
5-tier option
- Retail copay examples (Generic / Brand Formulary / Brand Non‑Formulary / Formulary Specialty / Non‑Formulary Specialty) include: $15/$30/$50/$100/$150; $20/$50/$100/$150/$250; $30/$80/$125/$250/20%.
- Mail‑order copays for 5‑tier examples include: $30/$60/$150; $40/$100/$300; $60/$160/$375.
- Mail order is not available for Specialty drugs under the 5‑tier option.

Out‑of‑plan pharmacy rules

For prescriptions filled at an Out‑of‑Plan retail pharmacy, a 20% coinsurance applies after the applicable copay.
Mail‑order prescriptions from Out‑of‑Plan providers are not covered.
Specialty drugs from Out‑of‑Plan providers are not covered.

Specialty drug handling

Specialty drugs may be subject to Tier 4 (Formulary Specialty) or Tier 5 (Non‑Formulary Specialty) as defined by the plan; mail order is explicitly unavailable for Specialty under the 5‑tier option.

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required for Brand-Name Drugs with Generic Equivalents

Prior authorization is required for requests to use a brand-name drug when an FDA‑approved generic equivalent exists. The provider must document medical necessity for the brand product (for example: inadequate therapeutic response to the generic, allergic reaction or intolerance to the generic, or clinical evidence that alternatives in the drug class have failed). Complete the Health New England drug request form and fax it with supporting clinical documentation for review. Incomplete submissions or lack of documented medical necessity may result in denial.

Affected items: Brand-name drugs with FDA‑approved generic equivalents (Tier 3 requests).
Required form: Health New England drug request form — completed and signed by the prescriber.
Documentation: clinical notes, prior trial evidence, allergy documentation, and any relevant lab results.
Submission: Fax completed form and supporting documentation to Health New England for prior authorization review.
Denial risk: Requests without documented medical necessity (e.g., no prior trial of generic or documented intolerance) are subject to denial.

Tier Definitions

Generic / Tier 1 — definition and notes

DefinitionGeneric/Tier 1: FDA-approved drugs with the same active ingredients as brand-name drugs; as safe and effective and usually cost less.

Massachusetts-specific noteIn Massachusetts, pharmacists are required to fill generics unless the prescriber writes 'no substitution' on the prescription.

Typical 3-tier example copay (from brief)Example retail copays for a 3-tier option: $10 (Generic).

Brand Formulary / Tier 2 — definition and typical copay position

DefinitionBrand Formulary/Tier 2: Brand drugs marketed under a trademarked name selected for the formulary based on safety, effectiveness and cost.

Cost positionCopay for Brand/Formulary drugs is higher than generic drugs, but lower than Brand/Non-Formulary drugs.

Typical copay examplesExample retail copays: $45 (Brand Formulary in 3-tier) and $30 (one of the Brand/Formulary levels in 5-tier).

Brand Non-Formulary / Tier 3 — definition and coverage notes

DefinitionBrand Non-Formulary/Tier 3: Any brand-name drug not designated as Brand/Formulary; still covered but at a higher or highest copay level.

Medical necessity & prior authorizationHealth New England covers brand drugs that have FDA-approved generic equivalents only if medical necessity is shown; providers may request prior authorization by submitting a drug request form with documentation (e.g., inadequate response or allergic reaction to generics and failure of alternatives).

Copay policyThese drugs are covered at the highest copay level in the 3-tier and at a higher copay level in the 5-tier; Health New England does not waive or reduce copays for Brand/Non-Formulary drugs.

Formulary Specialty / Tier 4 — definition and specialty handling

DefinitionFormulary Specialty/Tier 4: Specialty drugs selected for formulary specialty based on review of relative safety, effectiveness and cost.

Specialty handlingFormulary Specialty drugs are managed separately as Tier 4 specialty products and are selected following formulary review criteria.

Coverage levelThese medications are covered as Tier 4 in the 5-tier benefit structure; mail-order may not be available for specialty (per brief).

Non-Formulary Specialty / Tier 5 — definition and specialty handling

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

Coverage and copayThese medications are still covered but at the highest copay level as Tier 5 in the 5-tier structure.

Position versus formulary specialtyNon-Formulary Specialty drugs are those not chosen for Tier 4 and therefore receive the highest specialty copay and separate specialty management.