Prescription drug copay tiers and coverage rules
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Defines retail and mail-order copay amounts by drug tier and explains coverage rules, prior authorization for brand-name drugs with available generics, and Medicare Part D creditability notice for members.
No material clinical or coverage changes in this revision.
Prescription Drug Coverage Criteria
Prescription drug coverage criteria
Coverage and criteria for prescription drugs by tier and special rules:
Generic (Tier 1)
- Covered as Tier 1 (Generic).
- Definition: FDA‑approved generics contain the same active ingredients as brand‑name drugs, are as safe and effective, and usually cost less.
- Pharmacy substitution note: In Massachusetts, pharmacists are required to fill generics unless the prescriber writes 'no substitution' on the prescription.
- Retail/mail copay (example amounts shown elsewhere in policy): lower copay than brand tiers.
Brand Formulary (Tier 2)
- Covered as Tier 2 (Brand Formulary).
- Definition: Trademarked brand drugs without less expensive generic equivalents; selected based on safety, effectiveness, and cost.
- Copay: higher than generic but lower than non‑formulary.
Brand Non‑Formulary (Tier 3)
- Covered with criteria as Tier 3 (Brand Non‑Formulary).
- Definition: Brand name drugs not on the formulary; covered at the highest copay level.
- Coverage of brand drugs that have FDA‑approved generics requires demonstration of medical necessity.
- Prior authorization process: The prescriber may request prior authorization by completing and faxing a drug request form with documentation of medical necessity (e.g., inadequate response or allergic reaction to generic(s), failure of alternatives in the drug class).
ALL of the following
- Deductible: Prescription drugs are subject to the combined medical pharmacy deductible for this plan.
ALL of the following
- Medicare Part D notice: This prescription drug coverage option combined with this plan does not meet Medicare Part D creditable coverage requirements for 2026; Medicare‑eligible members should consider this when making enrollment decisions.
Copay Tiers, Deductible, and Coding Notes
| Generic / Tier 1 | Approved by the FDA, generic drugs contain the same active ingredients as brand name drugs, are just as safe and effective, and usually cost less. |
| Brand Formulary / Tier 2 | Brand/Formulary drugs marketed under a trademarked brand name that do not have less expensive generic equivalents; selected based on relative safety, effectiveness and cost. Copay is higher than generic but lower than Brand Non-Formulary. |
| Brand Non-Formulary / Tier 3 | Any brand name drug that is not a Brand/Formulary drug. These drugs are covered at the highest copay. Brand name drugs with FDA-approved generic equivalents are covered only if medical necessity is shown; prior authorization may be requested with documentation (e.g., inadequate response or allergic reaction to generics, failure of alternatives). |
Provider Requirements and Prior Authorization
Prior Authorization Required for Brand Drugs with Generics
Health New England requires prior authorization for brand-name drugs when an FDA-approved generic equivalent exists. To request an exception, the prescribing provider must submit a completed drug prior authorization request form with supporting clinical documentation demonstrating medical necessity (for example: inadequate response to the generic, documented allergy or intolerance to the generic, or failure of clinically appropriate alternatives within the drug class).
- Submit the completed drug prior authorization form and supporting documentation via fax to Health New England pharmacy prior authorization at the number on the member’s ID card or the provider portal.
- Include documentation such as prior medication history, chart notes, lab results, or allergy records that support the medical necessity for the brand product.
- Medical necessity considerations include inadequate response to the generic(s), allergic reactions or intolerance to the generic(s), and failure of alternatives in the drug class.
Tier Definitions
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