Understanding Your Medication Coverage
Posted on November 13, 2015
Have you ever gone to the pharmacy to pick up your new prescription only to have the pharmacy tell you it was declined by your insurance? This may happen for various reasons. Some medications have step therapy requirements and quantity limits, while others, like brand-name drugs that have a generic equivalent, may require prior authorization through Health New England.
Step Therapy
A step therapy medication is one that requires you to try an alternate medication first. If you are not successful with the step medication, the original medication may be approved. If you are a new Health New England (HNE) member, our pharmacy department will enter an authorization to allow a step therapy medication for four months after your policy begins, without prior authorization, as long as you fill the prescription each month. If you fail to fill the prescription at least once in 180 days, a new request will need to be submitted after the lapse.
Quantity and Other Limitations
Some drugs have quantity limitations allowing only a specified amount per month. If your provider feels that a quantity greater than the specified amount is medically necessary because the allowed dosage has not worked for your condition, he or she can submit a prior authorization request to be reviewed by the HNE pharmacy department.
Other drugs, such as certain compound medications, may require review by HNE for various reasons, including if the cost exceeds $75. “Compound” refers to the process of mixing drugs by a pharmacist or physician to fit the unique needs of a patient.
Brand-Name vs. Generic
Brand-name medications that have a generic equivalent will require prior authorization for the brand-name drug to be filled. Your doctor must submit clinical information as to why the generic drug cannot be used. If there is no medical reason why a generic medication cannot be used, the request will be denied.
Generic medications are less expensive copies of brand-name drugs that are required by the FDA to have exactly the same dosage, intended use, effects, safety and strength as the original drug. On average, the cost of a brand-name medication is $192, while generics average about $22. Massachusetts law requires that, if your prescription is written for a name-brand drug with an FDA approved generic, the generic must be filled (unless your prescription indicates “no substitutions”).
Health New England strives to make decisions that allow for both product availability and cost control. The above requirements have been established in an effort to address rising prescription costs. We have a Clinical Care Assessment Committee (CCAC) made up of approximately 16 local practicing physicians and pharmacists who look at the clinical effectiveness, safety and overall value of a drug. Based on their findings, they determine tier placement, prior authorization status, quantity limits and all other restrictions.
So, if your prescription is ever declined, you will have a better understanding of why. And then you can call HNE Member Services to find out what the requirements are for your medication.
For more information about step therapy, quantity limitations and prior authorization requirements, go to healthnewengland.com/HNE_Pharmacy or call Member Services, Monday – Friday, 8:00 a.m. – 6:00 p.m., at (413) 787-4004 or (800) 310-2835. For TTY/TTD: (800) 439-2370.
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