CurrentMass General Brigham Health PlanPolicy N/A

Mandatory Generic (brand-name drugs when an interchangeable generic exists)

This policy governs prior authorization requirements for requests to cover brand-name medications when an interchangeable generic is available under Mass General Brigham Health Plan commercial/exchange pharmacy benefit; it affects prescribers and pharmacy benefit adjudication.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMandatory Generic (brand-name drugs when an interchangeable generic exists)

Policy CodePolicy N/A

Change TypeMaterial and editorial updates

Effective Date01/01/2025

Next Review Date

Key ActionObtain prior authorization and provide documentation of prior generic trial or drug shortage when requesting a brand-name product.

SourceLink

POLICY UPDATE CHANGES

Drug shortage language and duration of approval (2 months) added as an authorization criterion.

Verbiage clarified to indicate that applicable medication-specific criteria means prior authorization or nonformulary criteria must be met.

2 monthsapproval duration for drug shortages

lifetimeapproval duration for other brand-name approvals

Commercial/Exchangeapplicable plan type

Prior Authprogram type

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Coverage Criteria for Brand-name Drugs

Covered with criteria

Authorization may be granted for brand name products when ONE of the following criteria has been met:

Approval criteria: Member has tried the generic formulation of the requested drug for the current indication and experienced an inadequate response or an adverse reaction.

Documentation of prior trial and inadequate response or adverse reaction required.

Approval criteria: Healthcare provider is requesting medication due to a drug shortage (documentation of drug shortage is required).

Approvals for drug shortages will be granted for 2 months.

Any quantity limits applicable to the generic formulation will also apply to the brand name.

Provider Actions and Authorization Rules

Prior Authorization

Prior Authorization Required

Prior authorization is required for a brand name drug when an interchangeable generic is available; requests are reviewed against this policy.

Step Therapy

No step therapy requirement specified in this policy.

Documentation Required

Required Documentation and Limitations

If requesting the brand because of a drug shortage, documentation of the drug shortage is required. Approvals for shortages will be granted for 2 months. All other approvals will be granted for the lifetime of the plan. If applicable, any medication-specific prior authorization or nonformulary criteria for the interchangeable generic must also be met. Any quantity limits applicable to the generic formulation will also apply to the brand-name product.

Denial Risk

Basis for Prior Authorization / Denial

Requests for brand-name drugs with an interchangeable generic will be subject to prior authorization and may be denied if the member has not tried the generic for the current indication and experienced an inadequate response or adverse reaction, unless approval is requested for a documented drug shortage. If the interchangeable generic has its own prior authorization criteria or is nonformulary, requests must also meet those applicable criteria.

Quantity Limits

Brand name (when interchangeable generic exists) — quantity limits and related rules

Quantity limit policyAny quantity limits applicable to the generic formulation will also apply to the brand name.

Approval duration for drug shortagesApprovals for drug shortages will be granted for 2 months.

Approval duration for other approvalsAll other approvals will be granted for the lifetime of plan.

Medication-specific criteriaIf applicable, any medication-specific prior authorization or nonformulary criteria for the generic must also be met.