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Some drugs may have to be approved before the plan covers them. This can apply to medicines that should be used only for certain medical conditions or are more costly than other drugs proven to be just as effective. For these drugs to be covered, health care providers must answer certain questions.
Search the requested drug. If pre-authorization is needed, the prescriber must complete the correct form with the appropriate clinical information completed.
Below you will find information about our formularies and how to look up prescription drugs covered under your plan. Please refer to your member ID card to identify which pharmacy plan type you have.
Providers: Find clinical criteria/policies below.
Health New England’s 3-Tier pharmacy plan option is cost-effective for members, who are able to access quality care and Health New England’s vast formulary of low-cost generics and $0 preventive care medications. The average member cost for a generic drug is less than $7.
TIER 1 = Generic
TIER 2 = Brand/Formulary
TIER 3 = Brand/Non-Formulary
For more information about your pharmacy coverage, please see your plan documents.
If you have Health New England’s 3-Tier pharmacy plan option, you will see 3 copay amounts listed next to “Pharmacy” on your Member ID card – see sample ID card below.
Click the 3-Tier sample ID card to search for a drug in the 3-Tier pharmacy formulary.
Click here to access the 3-Tier Pharmacy formulary booklet.
Health New England’s 5-Tier pharmacy plan option has 5 levels of copays and is cost-effective for members. The additional tiers call for higher copays on specialty drugs. Members are able to access quality care and Health New England’s vast formulary of low-cost generics and $0 preventive care medications. The average member cost for a generic drug is less than $7.
TIER 4 = Formulary Specialty Drugs
TIER 5 = Non-Formulary Specialty Drugs
If you have Health New England’s 5-Tier pharmacy plan option, you will see 5 copay amounts listed next to “Pharmacy” on your Member ID card – see sample ID card below.
Click the 5-Tier sample ID card to search for a drug in the 5-Tier pharmacy formulary.
Click here to access the 5-Tier Pharmacy formulary booklet.
Click the BeHealthy sample ID card to search for a drug in the BeHealthy pharmacy formulary, located on the MassHealth website.
Providers: Click here to access drug-specific Clinical Criteria/Policies and applicable forms for medications that require prior authorization.
Effective January 1, 2024, Health New England has expanded our HDHP drug benefit making select preventative drugs more affordable. Our expanded HDHP Preventive Drug List contains medications that are used for the prevention of or the recurrence of certain diseases. You will only pay your copay or coinsurance and will not have to meet your deductible first.
This drug list is subject to change and provided in accordance with the IRS guidance for HDHPs and any utilization management on these medications still applies.