Prescription drug copay tiers and mail order pricing
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Defines retail and mail-order copay amounts by drug tier, explains copay tiers and prior authorization/medical necessity for brand drugs, and notes Medicare Part D non-creditable status for 2024; applies to Health New England members.
No material clinical or coverage changes in this revision.
Prescription Drug Coverage Criteria
Prescription drug coverage tiers and exceptions
Covered according to tier with specified copays; brand-name drugs with FDA‑approved generics require documented medical necessity and may require prior authorization.
ALL of the following
- Generic / Tier 1: Generic/Tier 1 drugs: FDA‑approved generics containing the same active ingredients as the brand name drug; typically lower cost. Retail copay: $30; Mail order copay: $60.
In Massachusetts, pharmacists are required to fill generics unless the prescriber indicates 'no substitution' on the prescription.
- Brand Formulary / Tier 2: Brand Formulary/Tier 2 drugs: Brand drugs without less expensive generic equivalents selected based on safety, effectiveness, and cost. Retail copay: $120; Mail order copay: $240.
- Brand Non‑Formulary / Tier 3: Brand Non‑Formulary/Tier 3 drugs: Brand name drugs not on the formulary; covered at the highest copay. Retail copay: $200; Mail order copay: $600.
Deductible and Billing Notes
Provider Authorization & Documentation Requirements
Prior Authorization Required for Brand Drugs
Prior authorization is required for brand-name drugs when an FDA-approved generic equivalent exists. Providers must complete and submit a Health New England drug request form and include documentation demonstrating medical necessity. Acceptable documentation may include, but is not limited to, evidence of inadequate response to the generic, allergic reaction to the generic, or failure of other alternatives in the same drug class.
- Submit completed drug request form to Health New England (fax as instructed on the form).
- Provide documentation of medical necessity (examples: clinical notes, documented allergy to generic, trial and failure of generic or alternative agents).
- Note: Massachusetts law requires pharmacists to substitute generics unless the prescriber writes 'no substitution' on the prescription.
Drug Tier Definitions
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