Health-New-England Prior Authorization Lookup
- Health-New-England coverage criteria
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Latest Health-New-England prior authorization updates25
- Prior AuthReimbursement/Payment PolicyEff. 2026-01-01Pharmacy Benefit Copay Tier Options and Prior Authorization for Brand Drugs with GenericsDefines 3-tier and 5-tier pharmacy benefit options, associated member copays (including mail-order rules), tier definitions, prior authorization for brand-name drugs with generics, and specialty drug mail-order availability for Health New England HMO plans.All Health-New-England updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-01-01Pharmacy benefit tiered copay structureDefines 3-tier and 5-tier pharmacy benefit options, retail and mail-order copay amounts, tier definitions, and prior authorization/medical necessity rules for Health New England HMO Essential Plus 2000 LG members.All Health-New-England updates
- Prior AuthClinical/Medical PolicyEff. 2025-01-01Pharmacy Benefit Tier Definitions and Copay Structure (2025)Defines Health New England's 2025 pharmacy benefit tier options (3-tier and 5-tier) including copay amounts, tier definitions, and prior authorization/medical necessity rules for brand drugs; applies to HMO Focus LG members.All Health-New-England updates
- Prior AuthReimbursement/Payment PolicyEff. 2025-01-01Pharmacy benefit copay tiers and coverage rulesDefines 3-tier and 5-tier pharmacy benefit copay structures, mail-order rules, out-of-plan coverage, specialty drug handling, and prior authorization/medical necessity requirements for Health-New-England PPO plans referenced (national, MA). Affects members and prescribing providers under the listed plan options.All Health-New-England updates
- Prior AuthReimbursement/Payment PolicyEff. 2025-01-01Pharmacy benefit tiered copay structureDefines 3-tier and 5-tier pharmacy benefit options and copay amounts for HMO Essential Plus 2000 LG members, including descriptions of tiers, mail-order rules, and prior authorization for brand-name drugs when medical necessity is claimed.All Health-New-England updates
- Prior AuthClinical/Medical PolicyEff. 2021-01-01Behavioral health services coverage and prior authorizationDefines Health New England coverage, prior authorization requirements, and submission instructions for behavioral health and substance use disorder services for Commercial and Medicare Advantage members (HNE Be Healthy managed via MBHP).All Health-New-England updates
- Prior AuthClinical/Medical PolicyEff. 2021-01-01Pharmacy ServicesDefines Health-New-England's pharmacy benefit programs, formulary management, prior authorization, step therapy, quantity limits, specialty and compounded medication handling, and network/mail-order policies for members and providers.All Health-New-England updates
- Prior AuthClinical/Medical PolicyEff. 2021-01-01Prior Authorization for Outpatient Advanced Diagnostic Imaging, Sleep Studies, and Genetic TestingThis policy governs prior authorization requirements and utilization management for outpatient advanced diagnostic imaging (CT, MRI/MRA, PET, nuclear cardiology), sleep studies, and genetic lab testing for Health-New-England products. It affects ordering physicians and facilities rendering outpatient services.All Health-New-England updates
- Prior AuthAdministrative/Operational PolicyEff. 2021-01-01Procedures, Treatments and Services Requiring Utilization Management (Nonbehavioral Health)Defines services, procedures and treatments (non-behavioral health) that require prior authorization, notification, concurrent or retrospective review by Health New England and its delegates; applies to providers and facilities billing HNE plans.All Health-New-England updates
- Prior AuthClinical/Medical PolicyEff. 2021-01-01Utilization ManagementDefines Health New England's utilization management program policies, processes, and decision-making for prior authorization, concurrent and retrospective review, and technology assessment affecting providers and members served by HNE.All Health-New-England updates
- Prior AuthClinical/Medical Policy2025 Pharmacy Benefit — Brand Non‑Formulary Coverage CriteriaDefines copay tiers, mail order copay structure, and prior authorization/medical necessity rules for brand drugs under the Health-New-England 2025 Pharmacy Benefit for HMO Gold A SG plan. Affects prescribers, pharmacists, and plan members in the plan's service area.All Health-New-England updates
- Prior AuthClinical/Medical PolicyPharmacy benefit copay tiers and brand drug prior authorizationDefines copay tiers, mail-order copays, and prior authorization expectations for brand-name drugs under the 2026 Pharmacy Benefit for HMO Gold A SG plan; affects prescribers, pharmacists, and members of this HMO plan in applicable states.All Health-New-England updates
- Prior AuthClinical/Medical PolicyPharmacy benefit copay tiers and prior authorization for brand drugsDescribes copayment structure for the 2025 HMO Silver A SG pharmacy benefit and the prior authorization/medical necessity expectations for brand-name drugs versus generics; applies to Health-New-England members in the plan described.All Health-New-England updates
- Prior AuthClinical/Medical PolicyPharmacy benefit copay tiers and prior authorization for brand-name drugsDefines copay tiers, mail-order copays, deductible application for non-formulary drugs, and prior authorization / medical necessity requirements for brand-name prescriptions under the Health-New-England 2026 Pharmacy Benefit for HMO Silver A SG plan. Affects plan members and prescribers/pharmacists dispensing covered outpatient prescription drugs.All Health-New-England updates
- Prior AuthClinical/Medical PolicyPharmacy benefit copays and tiering for HMO Silver HDHP SGDefines copay tiers, mail order copays, deductible applicability, and prior authorization expectations for prescription drugs under the HMO Silver HDHP SG plan; affects providers prescribing and pharmacists dispensing medications for Health-New-England members in the plan.All Health-New-England updates
- Prior AuthReimbursement/Payment PolicyPharmacy benefit tiered copay structure (3-tier and 5-tier options)Defines 3-tier and 5-tier pharmacy benefit options, associated copays (including mail-order), coverage rules for out-of-plan pharmacies and specialty drugs, and prior authorization/medical necessity requirements for brand drugs. Applies to members of Health New England PPO Wise Plus 3000 National HDHP plans described in the document.All Health-New-England updates
- Prior AuthReimbursement/Payment PolicyPrescription drug copay tiers and coverage rulesDefines 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.All Health-New-England updates
- Prior AuthReimbursement/Payment PolicyPrescription drug copay tiers and mail order copaysDefines retail and mail-order copay amounts and explains the three copay tiers (Generic, Brand Formulary, Brand Non-Formulary) including prior authorization for brand-name drugs with generic equivalents. Applies to Health New England members to whom these benefit rules are offered.All Health-New-England updates
- Prior AuthReimbursement/Payment PolicyPrescription drug copay tiers and mail order pricingDefines 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.All Health-New-England updates
- Prior AuthReimbursement/Payment PolicyPrescription drug copayment tiers and prior authorization for brand-name drugsThis document defines retail and mail-order copay amounts by drug tier and explains tier definitions, coverage stance for brand drugs with generic equivalents, and the prior authorization requirement for medical necessity. It applies to Health New England members (Massachusetts referenced).All Health-New-England updates
- Prior AuthClinical/Medical PolicyPharmacy Benefit — HMO Silver 2000 HDHP SG: Copay Tiers and Prior Authorization for Brand-Name DrugsAll Health-New-England updates
- Prior AuthClinical/Medical PolicyPharmacy benefit copay tiers and prior authorization for brand drugsAll Health-New-England updates
- Prior AuthClinical/Medical PolicyPharmacy benefit copay tiers and prior authorization for brand drugsAll Health-New-England updates
- Prior AuthClinical/Medical PolicyPharmacy benefit copay tiers and prior authorization for brand-name drugsAll Health-New-England updates
- Prior AuthReimbursement/Payment PolicyPharmacy benefit tiers, copay structure and prior authorization for brand drugs with genericsAll Health-New-England updates
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Tool Description
Search Health-New-Englandprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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