Some drugs that are covered on Health New England’s formulary have additional requirements or limits on coverage. Here are three important terms for you to know and an explanation of what they mean:

Prior Authorization: Some drugs require prior authorization. This means that you will need to get approval from Health New England Medicare Advantage before you fill your prescriptions. If you do not obtain approval, we may not cover the drug. Ask your doctor for help with prior authorization if you need it.

Step Therapy: In some cases, Health New England Medicare Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

Quantity Limits: Certain drugs have limitations on the amount of the drug that Health New England Medicare Advantage will cover. If you notice a quantity limit on one of your drugs, be sure to mention this to your doctor to see what your options are.

You can find out if the drug you take is subject to these requirements or limitations by making an online request through the link below or by calling Member Services. If your drug is subject to one of these additional restrictions or limits and your physician determines that you aren’t able to meet the additional restriction or limit for medical necessity reasons, you or your physician may request an exception.

How do I request an exception to the Health New England Medicare Advantage Plan Formulary?

• Cover your drug even if it is not on our formulary.
• Waive coverage restrictions or limits on your drug. For example, for certain drugs, HNE Medicare Advantage limits the amount of the drug that we will cover. If you drug has a quantity limit, you can ask us to waive the limit and cover more.
• Provide a higher level of coverage for your drug. If your drug is contained in our non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier subject to the tiering exceptions process instead. This would lower the amount you must pay for your drug. (Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the specialty tier.)

Generally, Health New England Medicare Advantage will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request.

We generally must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement.

To submit a request or check on the status of a request for a coverage determination or redetermination, use the “Online Requests” button above. Usually, your prescriber will submit a request on your behalf. You or your prescriber may also use the NPS Coverage Determination Request Form or CMS Medicare Part D Coverage Determination Request Form.

You, your prescriber, treating provider, or authorized representative may contact us by mail, fax, or telephone at one of the addresses, fax, or telephone numbers provided on the Initial Decisions, Appeals, and Grievances page.

  Last Updated on 10/1/23