Pharmacy benefit tiered copay structure
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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.
No material clinical or coverage changes in this revision.
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
- Alternate retail copays (3-tier): $25 (Generic) / $50 (Brand Formulary) / $100 (Brand Non-Formulary).
- Alternate mail-order copays (3-tier): $50 (Generic) / $100 (Brand Formulary) / $300 (Brand Non-Formulary).
ALL of the following
- Tier names: Generic (Tier 1), Brand Formulary (Tier 2), Brand Non-Formulary (Tier 3), Formulary Specialty (Tier 4), Non-Formulary Specialty (Tier 5).
- Retail copays (5-tier): $20 (Tier 1) / $50 (Tier 2) / $100 (Tier 3) / $150 (Tier 4) / $250 (Tier 5).
- Mail-order copays (5-tier): $40 (Generic) / $100 (Brand Formulary) / $300 (Brand Non-Formulary).
Mail order is not available for Specialty drugs (Tiers 4 and 5).
ALL of the following
- Formulary Specialty (Tier 4) and Non-Formulary Specialty (Tier 5) designation: specialty drugs are selected based on review of safety, effectiveness, and cost.
- Non-Formulary Specialty (Tier 5) includes brand drugs not selected as Formulary Specialty and may include drugs with formulary generic and brand alternatives; these are covered at the highest copay level.
- Mail-order restriction: mail order is not available for specialty drugs.
ALL of the following
- Brand Non-Formulary drugs that have FDA-approved generic equivalents are covered only if medical necessity is shown.
- Prior authorization process: the provider may request prior authorization for a brand name drug by completing a drug request form and faxing documentation demonstrating medical necessity (e.g., inadequate response or allergic reaction to generics, failure of alternatives).
Prior Authorization & Dispensing Rules
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
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
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