CurrentHealth-New-EnglandPolicy N/A

Pharmacy benefit copay tiers and coverage rules

Defines 3-tier and 5-tier pharmacy benefit options, associated retail and mail-order copays, and coverage rules for in- and out-of-plan pharmacies and specialty drugs for Health New England PPO/HDHP plans.

Policy Summary

PayerHealth-New-England

PolicyPharmacy benefit copay tiers and coverage rules

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionSubmit a drug request form and fax documentation to request prior authorization for brand non-formulary drugs when medical necessity is demonstrated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3-/5-tierpharmacy benefit structures described

$10/$45/$75example retail copay set

$375highest mail-order copay

20%out-of-plan retail coinsurance

Not coveredmail-order out-of-plan coverage

Policy Summary

PayerHealth-New-England

PolicyPharmacy benefit copay tiers and coverage rules

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionSubmit a drug request form and fax documentation to request prior authorization for brand non-formulary drugs when medical necessity is demonstrated.

SourceLink

On This Page

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Pharmacy coverage criteria

Coverage and cost-sharing rules for pharmacy benefits by tier and provider source.

Member cost-sharing and coverage depend on the plan's pharmacy tier structure (3‑tier or 5‑tier) and whether the pharmacy is In‑Plan or Out‑of‑Plan.

Copay schedules (examples)

3‑tier retail copay examples include $10/$45/$75, $15/$30/$50, $15/$50/$100, $20/$40/$70, and $20/$50/$100 (Generic / Brand Formulary / Brand Non‑Formulary).
5‑tier retail copay examples include $15/$30/$50/$100/$150, $20/$50/$100/$150/$250, and $30/$80/$125/$250/20% (Generic / Brand Formulary / Brand Non‑Formulary / Specialty tiers as applicable).

Mail order copays are listed separately and are higher than retail examples; mail order amounts vary by schedule (examples: $20/$90/$225; $30/$60/$150; $40/$100/$300; $60/$160/$375).

Mail order is not available for Specialty drugs (5‑tier plans) and mail order prescriptions from Out‑of‑Plan providers are not covered.

Prescription drugs are subject to the combined medical/pharmacy deductible for the plan.

For prescriptions filled at an Out‑of‑Plan retail pharmacy, 20% coinsurance applies after the applicable copay.

Specialty drugs obtained from Out‑of‑Plan providers are not covered.

Coverage of Brand Non‑Formulary drugs / Prior authorization

Brand name drugs that have an FDA‑approved generic equivalent are covered only when medical necessity is demonstrated.
Medical necessity examples include inadequate response or allergic reaction to generic(s) and failure of alternatives in the drug class.
The prescriber may request prior authorization by completing a drug request form and faxing it to Health New England with supporting documentation of medical necessity for review.

Tier definitions

Generic / Tier 1: FDA‑approved generics with same active ingredients as brand drugs; pharmacists in Massachusetts must fill generic unless the prescriber writes 'no substitution'.
Brand Formulary / Tier 2: Brand drugs selected for formulary based on safety, effectiveness and cost; copay higher than generic but lower than non‑formulary.
Brand Non‑Formulary / Tier 3: Brand drugs not selected as formulary; still covered at the highest copay level; copays are not waived or reduced for non‑formulary brands.
Formulary Specialty / Tier 4 and Non‑Formulary Specialty / Tier 5: Specialty drugs categorized by formulary selection; Tier 5 includes non‑formulary specialty drugs with the highest copay, and mail order is not available for specialty tiers.

Plans may publish specific retail and mail order copay schedules; the examples above illustrate the range of copays and mail‑order amounts in the 2025 plan options.

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization for Brand/Non‑Formulary Drugs

Prior authorization may be required for Brand/Non‑Formulary (Tier 3) drugs. These are brand name drugs that are not on the Health New England formulary and/or have an FDA‑approved generic equivalent. Health New England covers Brand/Non‑Formulary drugs only when medical necessity is documented.

Prior authorization requests must be submitted using the Health New England drug request form and faxed to Health New England for review.
Medical necessity should be documented and may include, but is not limited to: inadequate response to the FDA‑approved generic(s), allergic reaction to the generic(s), or failure of alternatives in the same drug class.
Brand/Formulary (Tier 2) drugs are preferred over Brand/Non‑Formulary (Tier 3); Tier 3 drugs have the highest member cost share.
In Massachusetts, pharmacists are required to substitute generics unless the prescriber writes 'no substitution' on the prescription; a request for a brand product should include documentation supporting medical necessity when a generic is available.

Tier Definitions and Specialty Drug Categories

Generic / Tier 1

DefinitionFDA-approved generics with the same active ingredients as brand drugs; are as safe and effective and usually cost less.

Massachusetts substitution rulePharmacists in Massachusetts are required to fill generics unless the prescriber writes 'no substitution' on the prescription.

Cost implicationGeneric/Tier 1 copay is lower than Brand/Formulary and Brand/Non-Formulary copays (example 3-tier retail: $10 for Generic).

Brand Formulary / Tier 2

DefinitionBrand/Formulary drugs are marketed under a trademarked brand name, by one company, and do not have less expensive generic equivalents.

Selection criteriaSelected based on review of relative safety, effectiveness and cost of FDA‑approved drugs on the market.

Cost implicationCopay for Brand/Formulary (Tier 2) is higher than generic but lower than Brand/Non‑Formulary (example 3‑tier retail: $45 for Brand/Formulary).

Brand Non-Formulary / Tier 3

DefinitionBrand/Non‑Formulary drugs are any brand name drugs not designated as Brand/Formulary; these remain covered but at the highest copay level.

Generic equivalent ruleHealth New England covers brand name drugs that have FDA‑approved generic equivalents only if Medical Necessity is shown.

Prior authorizationA prescriber may request prior authorization by completing a drug request form and faxing it to Health New England with documentation (examples: inadequate response or allergic reaction to generics; failure of alternatives).

Specialty tiers (Tier 4 and Tier 5)

Formulary Specialty (Tier 4)Formulary Specialty drugs are selected based on review of relative safety, effectiveness and cost among FDA‑approved specialty products.

Non‑Formulary Specialty (Tier 5)Any brand specialty drug not selected as Formulary Specialty is Non‑Formulary Specialty; these include brand drugs with formulary generic and brand alternatives and are covered at the highest copay.

Coverage noteThese specialty tiers apply within the 5‑tier pharmacy benefit structure; Non‑Formulary Specialty carries the highest cost share.

OpenPayer

Pharmacy benefit copay tiers and coverage rules

Pharmacy Coverage and Cost-Sharing Rules

Provider Requirements and Prior Authorization

Tier Definitions and Specialty Drug Categories