CurrentHealth-New-EnglandPolicy N/A

Prescription drug copay tiers and mail-order coverage

Defines retail and mail-order copay tiers for generic, brand formulary/non-formulary, and specialty drugs, and notes coverage rules for out-of-plan and mail-order prescriptions. Applies to Health New England members (state-specific notes included).

Policy Summary

PayerHealth-New-England

PolicyPrescription drug copay tiers and mail-order coverage

Policy CodePolicy N/A

Change TypeNo material changes

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 out-of-plan prescriptions are not covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$60/$160/$375mail-order copay amounts

5copay tiers

20%out-of-plan coinsurance

restrictedmail-order specialty

Pharmacy Coverage Criteria

Pharmacy coverage criteria

Covered when the following pharmacy coverage rules are met:

Retail and mail-order coverage follows tiered copay structure across five tiers: Generic (Tier 1), Brand Formulary (Tier 2), Brand Non‑Formulary (Tier 3), Formulary Specialty (Tier 4), and Non‑Formulary Specialty (Tier 5).

See tier definitions for copay implications.

ALL of the following

Mail order copays (document example amounts): $60/$160/$375 (presented for applicable non‑specialty tiers).

ALL of the following

Mail order is not available for Specialty drugs.
Formulary Specialty (Tier 4) and Non-Formulary Specialty (Tier 5) are subject to this restriction.

Policy Summary

PayerHealth-New-England

PolicyPrescription drug copay tiers and mail-order coverage

Policy CodePolicy N/A

Change TypeNo material changes

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 out-of-plan prescriptions are not covered.

SourceLink

On This Page

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ALL of the following

Generic/Tier 1: FDA‑approved generics are equivalent to brand active ingredients; Massachusetts requires pharmacists to fill generics unless the prescriber writes 'no substitution'.
Brand Formulary/Tier 2: Covered at a higher copay than generic but lower than non‑formulary brand.
Brand Non‑Formulary/Tier 3: Covered at a higher copay; Health New England does not waive or reduce copays for Brand/Non‑Formulary drugs.
Formulary Specialty/Tier 4 and Non‑Formulary Specialty/Tier 5: Specialty categories are covered but subject to specialty restrictions and higher copays for Non‑Formulary Specialty.

Copay Tiers and Billing Notes

Generic / Tier 1mixed

Generic / Tier 1

Approved by the FDA; contains the same active ingredients as brand name drugs; pharmacists in Massachusetts required to fill generics unless prescriber orders 'no substitution'.

Brand Formulary / Tier 2mixed

Brand Formulary / Tier 2

Brand/formulary drugs selected based on safety, effectiveness and cost; copay higher than generic but lower than Brand Non-Formulary.

Brand Non-Formulary / Tier 3mixed

Brand Non-Formulary / Tier 3

Brand name drugs not selected as Brand/Formulary; covered at a higher copay; Health New England does not waive or reduce copays for Brand Non-Formulary drugs.

Formulary Specialty / Tier 4mixed

Formulary Specialty / Tier 4

Formulary specialty drugs selected based on safety, effectiveness and cost; mail order is not available for specialty drugs.

Non-Formulary Specialty / Tier 5mixed

Non-Formulary Specialty / Tier 5

Brand specialty drugs not selected as Formulary Specialty; covered at the highest copay level; may have formulary generic and brand alternatives.

Mail Order Copays (example amounts)mixed

Mail Order Copays

Generic / Brand Formulary / Brand Non-Formulary — $60 / $160 / $375; mail order is not available for Specialty drugs.

Out-of-Plan rulesmixed

Out-of-Plan retail	For prescriptions from an Out-of-Plan retail pharmacy, 20% coinsurance applies after copay.
Out-of-Plan mail order	Mail Order prescriptions from Out-of-Plan providers are not covered.
Out-of-Plan specialty	Specialty drugs from Out-of-Plan providers are not covered.

Out-of-plan coinsurance

Out-of-plan coinsurance20% coinsurance applies after the member copay for prescriptions obtained from an out-of-plan retail pharmacy.

Out-of-Plan & Mail Order Coverage Rules

Billing Rule

Out-of-Plan & Mail-Order billing and coverage rules

Providers should inform members that prescriptions filled at an Out-of-Plan retail pharmacy will be subject to a 20% coinsurance after the member’s applicable copay; mail-order prescriptions from Out-of-Plan providers are not covered, and specialty drugs obtained from Out-of-Plan providers are not covered. Verify network status before directing members to fill prescriptions to avoid these additional member costs or coverage denials.

Out-of-Plan retail pharmacy: 20% coinsurance applies after the copay.
Mail-order prescriptions from Out-of-Plan providers: not covered.
Specialty drugs from Out-of-Plan providers: not covered.

Tier Definitions

Generic / Tier 1

DefinitionGeneric/Tier 1 drugs are FDA‑approved products containing the same active ingredients as brand name drugs, are as safe and effective, and usually cost less.

Massachusetts pharmacist substitutionIn Massachusetts, pharmacists are required to fill generics unless the prescriber writes 'no substitution' on the prescription.

Coverage implicationThese drugs are assigned to the lowest copay tier (Tier 1).

Brand Formulary / Tier 2

DefinitionBrand Formulary/Tier 2 drugs are trademarked brand‑name products selected for the formulary based on relative safety, effectiveness, and cost.

Copay relationshipCopay for Brand/Formulary (Tier 2) is higher than Generic (Tier 1) but lower than Brand Non‑Formulary (Tier 3).

Coverage implicationThese drugs are covered under the formulary with a mid‑level copay.

Brand Non‑Formulary / Tier 3

DefinitionBrand Non‑Formulary/Tier 3 includes brand name drugs Health New England has not selected as Brand/Formulary.

Coverage and costThese medications are covered but at a higher copay level; Health New England does not waive or reduce copays for Brand Non‑Formulary drugs.

PositioningTier 3 copays are higher than Tier 2 and Tier 1.

Formulary Specialty / Tier 4

DefinitionFormulary Specialty/Tier 4 are specialty drugs selected based on relative safety, effectiveness, and cost among FDA‑approved drugs.

Mail‑order restrictionMail order is not available for specialty drugs.

Coverage implicationThese specialty drugs are placed in Tier 4 and subject to specialty drug cost‑sharing rules.

Non‑Formulary Specialty / Tier 5

DefinitionNon‑Formulary Specialty/Tier 5 includes brand specialty drugs Health New England has not selected as Formulary Specialty (Tier 4), often with formulary alternatives.

Cost and coverageThese medications are covered at the highest copay level among tiers and may have formulary generic or brand alternatives.

Out‑of‑plan ruleSpecialty drugs from out‑of‑plan providers are not covered.