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Health New England (HNE) covers most prescription drugs and a small number of non-prescription drugs and medical supplies. To provide cost-effective benefits, covered prescription drugs are divided into three tiers with different Member copayments. The copayment amounts are listed on your ID card. There are also a small number of drugs that are not covered or for which coverage is limited.

The copayment categories and coverage limits are explained below.

Generic Drugs (Tier 1)

“Generic Drugs” contain the same active ingredients as brand name drugs but are available at a lower cost. The Food and Drug Administration (FDA) reviews Generic Drugs to assure that they are safe and effective. HNE encourages the dispensing of Generic Drugs whenever possible. You pay the lowest copayment for Generic Drugs.

Brand/Formulary Drugs (Tier 2)

Brand name drugs are marketed under a trademarked brand name, usually by only one manufacturer. “Brand/Formulary Drugs” are brand name drugs selected by HNE based on a review of the relative safety, effectiveness and cost of the many FDA approved drugs on the market. Your copayment for Brand/Formulary Drugs is higher than for Generic Drugs but lower than for Brand/Non-Formulary Drugs, which are described below.

Brand/Non-Formulary Drugs (Tier 3)

Any brand name drug that HNE has not selected as a Brand/Formulary Drug is a “Brand/Non-Formulary Drug.” This category includes, but is not limited to, any brand name drug that has a generic equivalent. You pay the highest copayment for Brand/Non-Formulary Drugs.

Although HNE covers Brand/Non-Formulary Drugs with a higher copayment, there will usually be a Generic Drug or a Brand/Formulary Drug with a lower copayment that is appropriate for your condition.

Drugs For Which Coverage is Excluded or Limited

There are a small number of prescription drugs that are either not covered by HNE or for which coverage is limited. HNE Providers may request an exception, on behalf of a Member, for coverage of any drug that is excluded or limited. For more information see “Drug Coverage Policies and Exceptions.”

HNE covers only drugs that are Medically Necessary for preventive care or for treating illness, injury, or pregnancy. Drugs that are not covered include, but are not limited to, drugs for cosmetic purposes. HNE also limits the coverage of specific drugs for reasons of cost and to assure their safe and effective use. In some cases, HNE may limit the conditions a drug is prescribed for, and the quantity of the drug that is covered.

To find out if a drug is excluded, limited, or requires prior authorization, or to obtain a copy of the Health New England Formulary Listing, please call Customer Service at 413-787-4004 or 800-310-2835.

HNE is responsible for classifying drugs as Brand/Formulary Drugs and for establishing exclusions and limitations on drug coverage. HNE relies on input from a committee made up of physicians and pharmacists who are advised by physician consultants from a large number of medical specialties.

What Is Covered

Subject to the applicable copayment, your prescription drug benefit covers all Medically Necessary drugs that require a prescription by law, except drugs that HNE excludes or limits. Coverage includes the following to the extent Medically Necessary:

Refill prescriptions allowed by law and authorized by the prescribing physician;
Needles and syringes needed to administer covered drugs;
Oral contraceptives (birth control pills), diaphragms and cervical caps;
Off-label uses of drugs for the treatment of cancer and HIV/AIDS;
Compounded prescriptions, as long as one or more agents within the compound requires a prescription; and
The following non-prescription items when prescribed by an HNE Provider: insulin, nicotinic acid, and blood and urine diabetic testing strips.

How To Get Your Prescription Filled

Getting your prescriptions filled is easy. Just present your Health New England ID card at a participating pharmacy, along with your prescription or refill, and pay the applicable copayment. To find out which pharmacies participate with Health New England, please refer to Health New England’s Provider Directory.

Your Copayments

Copayments are the amounts you must pay for covered medications. They are listed on your ID card. As explained earlier, different copayments are charged for Generic Drugs (Tier 1), Brand/Formulary Drugs (Tier 2) and Brand/Non-Formulary Drugs (Tier 3).

Copayments must be paid to the pharmacy at the time of purchase. If the applicable copayment is more than the retail price of a drug, you pay the retail price*. Except as noted below, each copayment covers up to a 30-day supply of a prescription or refill. If your physician prescribes less than a 30-day supply of a medication, a full copayment applies. HNE may limit the amount of a drug available per 30-day period. In this case, each copayment applies to a 30-day supply as limited by HNE.

Member copayments for mail service may differ from your standard prescription copayments. Health New England’s mail service copayment covers up to a 90-day supply of a prescription or refill. For more information on mail service coverage see “Mail Service Prescriptions.”

* Retail prices for drugs may vary from pharmacy to pharmacy. Please ask your pharmacist if the retail price of your drug is less than the applicable copayment.

Exclusions and Limitations of Coverage

HNE does not cover the following:

Drugs that are not Medically Necessary for preventive care or for treating illness, injury or pregnancy;
Drugs that HNE specifically excludes, including, but not limited to, drugs for cosmetic purposes;
Drugs in excess of coverage limitations imposed by HNE. Limitations may be placed on either the quantity of a drug covered or the medical conditions for which a drug may be prescribed;
Non-prescription items, other than those specifically listed previously;
Drugs that have not been approved by the FDA;
Prescriptions written by providers who are not authorized to do so by HNE;
Drugs prescribed as part of a course of treatment that HNE does not cover;
Prescriptions filled at non-participating pharmacies. An exception to this requirement is described on the next page for care covered outside of the HNE Service Area;
Drugs that must be administered by a health care professional. Such drugs may be covered through the provider but may not be purchased by a Member under this benefit.

Drugs Purchased Outside the HNE Service Area

While you are temporarily outside of the HNE Service Area, you are covered for prescription drugs needed for an unforeseen illness or injury. In most cases you will have to pay for drugs you obtain outside the Service Area and send a request for reimbursement with a copy of your prescription receipt. Please see your Member Agreement for information on claims procedures. HNE will pay eligible claims minus the applicable copayment. Payment is limited to the Usual, Customary and Reasonable Charge for the drug.

Mail Service Prescriptions

HNE provides a mail service option for Members who wish to receive their prescriptions through the mail. Only medications for which a 90-day supply is appropriate may be obtained by mail. Member copayments for mail service prescriptions may differ from your standard prescription copayments. Each copayment covers up to a 90-day supply of a prescription or refill.

The following items may not be purchased through the mail service:
Compounded medications requiring the mixing of drugs by a pharmacist;
Any drugs for which mail service is prohibited by law; and
Prescriptions for which a 90-day supply may not be appropriate as determined by HNE.

Drug Coverage Policies and Exceptions

HNE regularly reviews prescription drugs and may add drugs to or remove drugs from the list of Brand/Formulary Drugs at any time. Notification of changes in the list of Brand/Formulary Drugs will not be sent to Members.

The Committee may require prior authorization for coverage of certain drugs including Brand/Formulary Drugs.

The Committee may add drugs to the list of drugs for which coverage is excluded or limited at any time without prior notice to Members. HNE Providers may request an exception on behalf of a Member for coverage of any drug that is excluded or limited. Exceptions will be granted only for clinical reasons.

HNE generally does not grant Members individual exceptions to the classification of a drug as a Brand/Non-Formulary Drug. Likewise, HNE generally does not waive the applicable copayment required for any Brand/Non-Formulary Drug. However, HNE Providers may request the review of a drug for designation as a Brand/Formulary Drug at any time.

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