Pharmacy benefit copay tiers and coverage rules
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Defines 3-tier and 5-tier pharmacy benefit options, associated retail and mail-order copays, and coverage rules for in-network, out-of-plan, mail-order, and specialty drugs for Health New England members.
No material clinical or coverage changes in this revision.
Coverage and Cost-Sharing Rules
Coverage criteria and billing rules
Covered with the following coverage and billing rules for the listed pharmacy benefit options:
ALL of the following
Copay schedules
- Multiple retail and mail‑order copay schedules are defined for 3‑tier and 5‑tier plan options (examples include retail $10/$45/$75 with mail‑order $20/$90/$225; retail $15/$30/$50/$100/$150 with mail‑order $30/$60/$150; and other variant schedules shown).
See plan copay tables for member‑specific option.
- Formulary tiers: Generic/Tier 1, Brand Formulary/Tier 2, Brand Non‑Formulary/Tier 3; 5‑tier options additionally include Formulary Specialty/Tier 4 and Non‑Formulary Specialty/Tier 5.
- Prescription drugs are subject to the combined medical and pharmacy deductible for the plan.
- For prescriptions obtained from an Out‑of‑Plan retail pharmacy, 20% coinsurance applies after the applicable copay.20% coinsurance after copay
- Mail order prescriptions from Out‑of‑Plan providers are not covered.
- Specialty drugs obtained from Out‑of‑Plan providers are not covered.
- Mail order is not available for Specialty drugs (applies to 5‑tier specialty mail order restriction).
- Coverage of brand name drugs that have FDA‑approved generic equivalents requires demonstration of medical necessity; prior authorization may be requested by the prescriber using the drug request form with documentation (for example: inadequate response or allergic reaction to generic(s), or failure of alternatives in the drug class).
Copays, Coinsurance, and Code Reference
| $10/$45/$75 | Generic / Brand Formulary / Brand Non-Formulary |
| $15/$30/$50 | Generic / Brand Formulary / Brand Non-Formulary |
| $15/$50/$100 | Generic / Brand Formulary / Brand Non-Formulary |
| $20/$40/$70 | Generic / Brand Formulary / Brand Non-Formulary |
| $20/$50/$100 | Generic / Brand Formulary / Brand Non-Formulary |
| $20/$90/$225 | Mail Order Copays Generic / Brand Formulary / Brand Non-Formulary |
| $30/$60/$150 | Mail Order Copays Generic / Brand Formulary / Brand Non-Formulary |
| $30/$100/$300 | Mail Order Copays Generic / Brand Formulary / Brand Non-Formulary |
| $40/$80/$210 | Mail Order Copays Generic / Brand Formulary / Brand Non-Formulary |
| $40/$100/$300 | Mail Order Copays Generic / Brand Formulary / Brand Non-Formulary |
| $15/$30/$50/$100/$150 | Generic / Brand Formulary / Brand Non-Formulary / Formulary Specialty / Non-Formulary Specialty |
| $20/$50/$100/$150/$250 | Generic / Brand Formulary / Brand Non-Formulary / Formulary Specialty / Non-Formulary Specialty |
| $30/$80/$125/$250/20% | Generic / Brand Formulary / Brand Non-Formulary / Formulary Specialty / Non-Formulary Specialty |
| $30/$60/$150 | Mail Order Copays Generic / Brand Formulary / Brand Non-Formulary (Mail order is not available for Specialty drugs) |
| $40/$100/$300 | Mail Order Copays Generic / Brand Formulary / Brand Non-Formulary (Mail order is not available for Specialty drugs) |
| $60/$160/$375 | Mail Order Copays Generic / Brand Formulary / Brand Non-Formulary (Mail order is not available for Specialty drugs) |
Prior Authorization and Provider Requirements
Prior authorization required for brand-name drugs with generic equivalents
Health New England allows coverage of brand-name drugs that have FDA‑approved generic equivalents only when medical necessity is demonstrated. To request coverage, the prescribing provider must complete a drug request form and fax it to Health New England for review, including documentation supporting medical necessity (for example: inadequate response or allergic reaction to the generic(s) and failure of alternatives in the drug class).
- Complete and fax the Health New England drug request form to request prior authorization for a brand-name drug that has a generic equivalent.
- Include documentation of medical necessity: examples include inadequate response to generics, allergic reaction to generics, and failure of alternatives in the drug class.
- Prior authorization will be reviewed by Health New England and coverage granted only when medical necessity is shown.
Tier Definitions and Specialty Drug Notes
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