CurrentHealth-New-EnglandPolicy N/A

5-tier pharmacy benefit copay structure

Defines the 5-tier pharmacy benefit copay and mail-order rules for Health New England PPO Essential Care National plans and explains tier definitions and out-of-plan coverage limits.

Policy Summary

PayerHealth-New-England

Policy5-tier pharmacy benefit copay structure

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFor prescriptions from an Out-of-Plan retail pharmacy, 20% coinsurance applies after copay; mail-order and specialty prescriptions from Out-of-Plan providers are not covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5pharmacy tiers described

$15/$30/$50/$100/$150retail copay example

$30/$60/$150mail order copays

20%out-of-plan retail coinsurance

excludedout-of-plan mail-order

Pharmacy Coverage Criteria

Pharmacy coverage criteria

Coverage and cost-sharing rules for retail and mail-order pharmacy under the 5‑tier structure.

ALL of the following

Example retail/mail‑order schedules
- Example schedule A (retail): $15/$30/$50/$100/$150; Mail Order: $30/$60/$150.
- Example schedule B (retail): $15/$50/$100/$150/$250; Mail Order: $30/$100/$300.
- Example schedule C (retail): $20/$50/$100/$150/$250; Mail Order: $40/$100/$300.
- Example schedule D (retail): $25/$50/$150/$250/20%; Mail Order: $50/$100/$450.

Policy Summary

PayerHealth-New-England

Policy5-tier pharmacy benefit copay structure

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFor prescriptions from an Out-of-Plan retail pharmacy, 20% coinsurance applies after copay; mail-order and specialty prescriptions from Out-of-Plan providers are not covered.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ALL of the following

Tier 1 (Generic): FDA‑approved generics with the same active ingredients as brand drugs; generally lower cost. In Massachusetts pharmacists must fill generic unless prescriber specifies 'no substitution'.
Tier 2 (Brand Formulary): Brand drugs selected for the formulary based on safety, effectiveness and cost; copay higher than generics but lower than non‑formulary.
Tier 3 (Brand Non‑Formulary): Brand drugs not selected as formulary; covered at a higher copay. Health New England does not waive or reduce copays for Brand/Non‑Formulary drugs.
Tier 4 (Formulary Specialty): Specialty drugs selected for formulary after review of safety, effectiveness and cost.
Tier 5 (Non‑Formulary Specialty): Specialty brand drugs not selected as formulary specialty; include drugs with formulary alternatives and carry the highest copay.

Copay Schedules and Coinsurance

Example retail copay schedule option 1mixed

$15/$30/$50/$100/$150

Retail copay schedule: Generic / Brand Formulary / Brand Non-Formulary / Formulary Specialty / Non-Formulary Specialty

Example mail-order copays corresponding to option 1mixed

$30/$60/$150