Prescription drug copay tiers and amounts
Defines retail and mail-order copay amounts by drug tier and describes tier definitions and coverage implications for Health-New-England members. Applies to members in the plan's service area (document references Massachusetts).
No material clinical or coverage changes in this revision.
Coverage by Copay Tier
Copay-based coverage stance
Coverage is structured by copay tier; all listed categories are covered but at differing copay levels. Mail-order availability is limited (specialty drugs are not available by mail order).
Copay tiers (retail)
- Generic / Tier 1 — Retail copay: $30; FDA-approved generics; typically lower cost.
- Brand Formulary / Tier 2 — Retail copay: $80; brand drugs selected for the formulary after review of safety, effectiveness and cost; higher copay than generics but lower than non-formulary brands.
- Brand Non-Formulary / Tier 3 — Retail copay: $125; brand drugs not selected as formulary; covered at a higher copay and copays are not waived or reduced.
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