CurrentMass General Brigham Health PlanPolicy N/A

Brand Preferred

Policy governing prior authorization for coverage of brand-name medications when a generic equivalent exists for Commercial/Exchange pharmacy benefit members; defines clinical criteria, documentation requirements, and approval durations.

Policy Summary

PayerMass General Brigham Health Plan

PolicyBrand Preferred

Policy CodePolicy N/A

Change TypeUpdated: drug shortage language and approval durations

Effective DateMay 1, 2023

Next Review Date

Key ActionPrescriber must request prior authorization and provide medical records documenting inadequate response or adverse reaction to the preferred version and document drug name, dose, and frequency; if for a drug shortage, document the shortage.

SourceLink

POLICY UPDATE CHANGES

Added drug shortage language and duration of approval.

Created brand preferred over generic criteria.

Commercial/ExchangeApplicable Plan

Prior AuthorizationProgram Type

Pharmacy BenefitBenefit

Coverage Summary

Policy governing prior authorization for coverage of brand-name medications when a generic equivalent exists for Commercial/Exchange pharmacy benefit members. The plan covers with criteria—authorization may be granted when the specified criteria and documentation are provided. Effective 05/01/2023. Approvals will be granted for 12 months, while approvals based on documented drug shortage will be granted for 2 months.

Authorization / Prior Authorization Criteria

Authorization Criteria

Authorization may be granted for members when ALL the following criteria are met, and documentation is provided:

ALL of the following

ONE of the following
- The member has tried the brand therapeutically equivalent to the non-preferred generic product requested
- MD is requesting medication due to a drug shortage (Must document drug shortage)
  Refer to policy definition: documentation of drug shortage required
The provider documents drug name, dose and frequency, and if member had adverse reaction, intolerance and/or contraindication to the BRAND medication

Approvals will be granted for 12 months; approvals based on documented drug shortage will be approved for 2 months.

Provider Actions & Authorization Workflow

Prior Authorization

Prior authorization required for brand over generic

Prescriber must request prior authorization and provide medical records documenting inadequate response or adverse reaction to the preferred version and document drug name, dose, frequency; PA may still be required for clinical reasons noted on Drug Look Up.

Documentation Required

Documentation of drug shortage

If request is due to drug shortage, prescriber must document the drug shortage to qualify under the criteria. Drug shortage is defined as a documented lack of supply of the preferred product as attested by the prescriber; documentation is required to qualify for shortage-based approval.

Billing Rule

Approval duration

Approvals will be granted for 12 months; approvals based on documented drug shortage will be approved for 2 months.

Background & Definitions

Mass General Brigham Health Plan prefers certain brand name medications over their generic equivalents. When requesting the non-preferred (brand) version, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to meeting the drug-specific criteria. Additional prior authorization requirements may apply; drugs requiring extra PA will be noted on Drug Look Up.

Drug shortage: A documented lack of supply of the preferred product as attested by the prescriber; documentation is required to qualify for shortage-based approval.