Pharmacy Benefit Copay Tier Options and Prior Authorization for Brand Drugs with Generics
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Defines 3-tier and 5-tier pharmacy benefit options, associated member copays (including mail-order rules), tier definitions, prior authorization for brand-name drugs with generics, and specialty drug mail-order availability for Health New England HMO plans.
No material clinical or coverage changes in this revision.
Pharmacy Benefit Coverage Options & Rules
Pharmacy Benefit Coverage Criteria
Coverage is provided under either a 3‑tier or 5‑tier pharmacy benefit configuration with specified retail and mail‑order copays, mail‑order specialty restrictions, and requirements for prior authorization of brand drugs when generics exist.
ALL of the following
Tier structure (choose one)
- 3-Tier Options: 3‑tier schedules apply with tiers: Generic (Tier 1), Brand Formulary (Tier 2), Brand Non‑Formulary (Tier 3). Example retail copay schedules include $15/$50/$75 and $25/$50/$100. Corresponding mail‑order copays examples: $30/$100/$225 and $50/$100/$300.
- 5-Tier Options: 5‑tier schedules apply with tiers: Generic (Tier 1), Brand Formulary (Tier 2), Brand Non‑Formulary (Tier 3), Formulary Specialty (Tier 4), Non‑Formulary Specialty (Tier 5). Example retail and mail‑order copays include $15/$30/$50/$100/$150 with mail order $30/$60/$150 and multiple other 5‑tier variants shown in plan materials.
ALL of the following
- Generic / Tier 1
FDA‑approved generics have same active ingredients as brand drugs; in Massachusetts pharmacists must fill generics unless prescriber indicates 'no substitution'.
- Brand Formulary / Tier 2
Trademarked brand drugs selected for formulary based on safety, effectiveness and cost; copay higher than generics but lower than non‑formulary brands.
- Brand Non‑Formulary / Tier 3
Brand drugs not selected as formulary; covered at higher copay. Brand name drugs with FDA‑approved generics require medical necessity for coverage.
- Formulary Specialty / Tier 4
Specialty drugs selected for formulary based on safety, effectiveness and cost.
- Non‑Formulary Specialty / Tier 5
Specialty brand drugs not selected as formulary specialty; covered at the highest copay level.
ALL of the following
- Mail‑order copays are specified per tier schedules and vary by plan and tier.
- Mail order is not available for Specialty drugs.
ALL of the following
- Health New England covers brand name drugs that have FDA‑approved generic equivalents only if medical necessity is shown.
- Provider may request prior authorization by completing and faxing a drug request form to Health New England with documentation of medical necessity (examples include inadequate response or allergic reaction to generics and failure of alternatives in the drug class).
ALL of the following
- Brand/Formulary and Brand/Non‑Formulary tiers have higher copays than generics.
- Health New England does not waive or reduce copays for Brand/Non‑Formulary drugs (5‑tier description).
Provider Requirements and Prior Authorization
Prior Authorization Required for Brand Name Drugs with Generics
Health New England requires prior authorization for brand name drugs when an FDA-approved generic equivalent exists. The provider must document medical necessity for the brand product and submit a completed drug request form along with supporting clinical documentation. Medical necessity may include, but is not limited to, inadequate response to the generic, allergic reaction or intolerance to the generic(s), or failure of other alternatives in the drug class.
- Submit a completed drug request form to Health New England for review.
- Include supporting documentation demonstrating medical necessity (e.g., allergy documentation, clinical notes showing inadequate response, trial history of alternatives).
- Prior authorization is required for brand-name drugs with FDA-approved generic equivalents; coverage granted only when medical necessity is demonstrated.
- In Massachusetts, pharmacists are required to substitute generic drugs unless the prescriber writes 'no substitution' on the prescription; provider documentation must address this when requesting brand coverage.
Tier Definitions and Drug Category Descriptions
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