Pharmacy benefit tiered copay structure (3-tier and 5-tier options)
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Defines 3-tier and 5-tier pharmacy benefit options, associated copays (including mail-order), coverage rules for out-of-plan pharmacies and specialty drugs, and prior authorization/medical necessity requirements for brand drugs. Applies to members of Health New England PPO Wise Plus 3000 National HDHP plans described in the document.
No material clinical or coverage changes in this revision.
Pharmacy Benefit Coverage & Cost-Sharing Rules
Brand drug medical necessity conditions
Providers may request prior authorization by submitting a drug request form and supporting clinical documentation to Health New England for review.
Prior Authorization and Provider Requirements
Prior authorization required for brand drugs when generics exist
Your doctor may request prior authorization for a brand name drug by filling out a drug request form and faxing it to Health New England for review with documentation of medical necessity.
- Include documentation demonstrating medical necessity (e.g., inadequate response or allergic reaction to generics, failure of alternatives in the drug class).
- Complete the Health New England drug request form and fax it per payer instructions.
Tier Definitions and Specialty Notes
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