CurrentHealth-New-EnglandPolicy N/A

Pharmacy benefit tiered copay structure

Defines 3-tier and 5-tier pharmacy benefit options and copay amounts for HMO Essential Plus 2000 LG members, including descriptions of tiers, mail-order rules, and prior authorization for brand-name drugs when medical necessity is claimed.

Policy Summary

PayerHealth-New-England

PolicyPharmacy benefit tiered copay structure

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders 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.

33-tier option

55-tier option

$20/$60/$903-tier retail copays

$20/$50/$100/$150/$2505-tier retail copays

$40/$120/$2703-tier mail-order

Tiered Pharmacy Coverage & Copays

Tier-based coverage and copays

Coverage is organized by pharmacy tiers. Copays vary by tier and by retail versus mail-order supply. Specialty drugs have specific tiering and mail-order rules.

ALL of the following

3-tier option
- Tier names: Generic (Tier 1), Brand Formulary (Tier 2), Brand Non-Formulary (Tier 3).
- Example retail copays (3-tier): $20 (Generic) / $60 (Brand Formulary) / $90 (Brand Non-Formulary).
- Example mail-order copays (3-tier): $40 (Generic) / $120 (Brand Formulary) / $270 (Brand Non-Formulary).
alternate 3-tier retail/mail order option

Policy Summary

PayerHealth-New-England

PolicyPharmacy benefit tiered copay structure

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders may request prior authorization for a brand-name drug by submitting a drug request form and faxing documentation of medical necessity.

SourceLink

On This Page

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Prior Authorization & Dispensing Rules

Prior Authorization

Prior Authorization Required for Brand-Name Drugs

Health New England requires prior authorization for brand-name drugs when a medically-appropriate generic alternative exists. Providers must submit a completed drug request form and supporting documentation demonstrating medical necessity. Medical necessity may include, but is not limited to, inadequate response or allergic reaction to the generic(s) and failure of alternatives in the drug class. Fax the drug request form and documentation to Health New England for review before billing for the brand-name medication.

Submit completed drug request form
Include documentation of medical necessity (e.g., trial history, allergy documentation)
Fax the request form and supporting documents to Health New England for review

Note

Mail-Order Restriction for Specialty Drugs

Mail-order is not available for Specialty drugs under this pharmacy benefit; specialty medications must be dispensed through approved specialty pharmacies or as directed by Health New England.

Mail order copays apply to Generic/Brand Formulary/Brand Non-Formulary where available
Specialty drugs are excluded from mail-order fulfillment

Tier Definitions

Generic / Tier 1

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

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

Cost implicationTypically the lowest copay level within the tiered pharmacy benefit.

Brand Formulary / Tier 2

DefinitionBrand Formulary/Tier 2: Brand drugs marketed under a trademarked name that do not have less expensive generic equivalents and are selected based on relative safety, effectiveness, and cost.

Placement rationalePlaced above generics because copays are higher than Tier 1 but lower than non-formulary brands; selection based on formulary review of safety, effectiveness and cost.

Cost implicationHigher copay than generics but lower than Brand Non-Formulary (Tier 3).

Brand Non-Formulary / Tier 3

DefinitionBrand Non-Formulary/Tier 3: Any brand-name drug not designated as Brand Formulary; covered but at a higher (3-tier) or highest (5-tier) copay level.

Coverage requirement for brands with genericsHealth New England covers brand-name drugs that have FDA-approved generic equivalents only if medical necessity has been shown; providers may request prior authorization with documentation (e.g., inadequate response or allergic reaction to generics).

Copay implicationIn a 3-tier plan: highest copay level; in a 5-tier plan: higher copay than Tier 2, and copays are not waived or reduced for Brand Non-Formulary drugs.

Formulary Specialty / Tier 4

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

PlacementClassified as Tier 4 in a 5-tier pharmacy benefit to distinguish specialty drugs selected for formulary from non-formulary specialty products.

Coverage noteThese drugs are covered under specialty tier rules and subject to specialty benefit controls (e.g., mail-order restrictions).

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.

Coverage and cost-sharing implicationThese medications are still covered but at the highest copay level (Tier 5) under the 5-tier benefit structure.

Placement rationalePlaced in the highest specialty tier to reflect non-formulary status and higher member cost sharing compared with Formulary Specialty (Tier 4).